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MEDICAL GUIDE AND MONOGRAPH SERIES 

GOLDEN RULES 

OF 

DIAGNOSIS AND TREATMENT 

OF DISEASES 



APHORISMS, OBSERVATIONS, AND PRECEPTS ON THE 

METHOD OF EXAMINATION AND DIAGNOSIS OF 

DISEASES, WITH PRACTICAL RULES FOR 

PROPER REMEDIAL PROCEDURE. 



BY 

HENRY A. CABLES, B. S., M. D. 

PROFESSOR OP MEDICINE AND CLINICAL MEDICINE OF THE COLLEGE OF PHYSI- 
CIANS AND SURGEONS, ST. LOUIS; CONSULTANT AT JEFFERSON HOSPITAL, 
ST. LOUIS; FORMERLY HOUSE PHYSICIAN AT ALEXIAN BROTHERS' 
HOSPITAL, ST. LOUIS; MEMBER OF THE AMERICAN MEDICAL 
ASSOCIATION, ILLINOIS STATE MEDICAL SOCIETY, ETC. 



ST. LOUIS 
C. V. MOSBY COMPANY 

1911 






COPYBIGHT, 1911, BY C. V. MOSBY COMPANY 



Press of 

C. V. Mosby Company 

St. Louis 



©CI.A283597 



PREFACE. 

Extensive treatises have been written on the 
diagnosis and treatment of diseases, the number of 
the diseases considered and the character of their 
description varying in the various volumes devoted 
to these subjects. While these treatises serve their 
purpose, there are many urgent instances when the 
physician needs a book of ready reference of diag- 
nosis, treatment, and remedial procedure. To meet 
this condition, and to assist the busy physician and 
the progressive student in obtaining the needed 
information readily and authentically, this book 
has been prepared. 

This book is an epitome of a careful and exten- 
sive examination of the literature on the subjects 
considered, supplemented by the author's experience 
in private and hospital practice, and the method of 
compilation and manner of presentation of demon- 
strated facts have been found to be the best for 
the purpose in view. Importance has been attached 
to the clinical methods of diagnosis, but at the 
same time the author feels that the laboratory has 
been drawn upon as often as necessary, as a phy- 
sician who attempts to make all diagnoses by the 
laboratory route will find the way fraught with 
tedium and uncertainty. 

The suggestions for treatment have been gleaned 
from authoritative current literature and standard 



6 PKEFACE. 

works. A variety of drugs have been named under 
some of the subjects, as the author believes that 
some good can be accomplished by correct medi- 
cation. In many cases there is, on the part of the 
physician, a lack of knowledge of proper thera- 
peutic technic, and the haphazard way of treat- 
ment is to be deprecated. The clinical aspect of 
the individual case should be studied, and treat- 
ment followed accordingly. Too often a physician 
administers to the patient the first cardiac stimu- 
lant that occurs to him, regardless of the fact that 
such a stimulant in the particular case is extremely 
dangerous. To exemplify another condition, it can 
be said that quinin is an exceedingly useful friend 
in small doses in certain affections, because of its 
power of increasing or calling out the body de- 
fenses, but in large oft-repeated doses it will have 
a disastrous effect, causing paralysis of the body 
defense by destroying the ameboid functions of 
the cells. 

This book is presented with a firm belief that a 
study of it will assist in making a correct diag- 
nosis, indicate the proper therapeutic procedure, 
and aid in fixing in the mind valuable information 
that can be readily recalled when needed. 

Heney A. Cables. 



CONTENTS. 

CHAPTER I. 

PAGE 

Diseases of the Stomach , 9 

Gastric Ulcer, 9; Gastric Cancer, 15; Gastritis, 18; Hyper- 
chlorhydria, 22; Hematemesis, 24. 

CHAPTER II. 

Diseases of the Intestines .26 

Acute Enteritis, 26; Chronic Enteritis, 30; Obstruction of 
the Bowel, 32 ; Chronic Constipation, 34 ; Appendicitis, 37 ; 
Mucous Colitis, 40; Viceroptosis, 41. 

CHAPTER III. 

Diseases of the Liver .45 

Icterus (Jaundice), 45; Portal Cirrhosis (Laennec's Cir- 
rhosis, Alcoholic Cirrhosis), 47; Biliary Cirrhosis, 51; 
Abscess of the Liver, 52; Acute Yellow Atrophy, 54; 
Cancer of the Liver, 55. 

CHAPTER IV. 

Diseases of the Gallbladder 57 

Gallstones, 57; Suppurative Cholangeitis, 60. 

CHAPTER V. 

Diseases of the Pancreas and Peritoneum 62 

Hemorrhage, 62; Acute Pancreatitis, 63; Chronic Pancrea- 
titis, 64 ; Pancreatic Cysts, 65 ; Carcinoma of the Pancreas, 
66; Acute Peritonitis, 68. 

CHAPTER VI. 

Diseases of the Kidneys and Bladder . . . . . ' ., . 71 
Movable Kidney, 71; Acute Nephritis, 73; Chronic Paren- 
chymatous Nephritis, 78; Chronic Interstitial Nephritis, 
81; Uremia, 84; Pyelitis, 89; Hydronephrosis, 91; Nephro- 
lithiasis, 92; Cystitis, 98. 



8 CONTENTS. 

CHAPTER VII. 

PAGE 

Diseases of the Blood 102 

Chlorosis, 102; Pernicious Anemia^ 106; Leukemia, 108; 
Pseudoleukemia (Hodgkin's Disease), 110; Purpura, 113. 

CHAPTER VIII. 

Diseases of the Ductless Glands 116 

Addison's Disease, 116; Exophthalmic Goiter, 118; Myx- 
edema, 123. 

CHAPTER IX. 

Diseases of the Vascular System 127 

Pericarditis, 127; Acute Endocarditis, 132; Malignant Endo- 
carditis, 132; Valvular Disease of the Heart, 135; Palpita- 
tion, 152; Angina Pectoris, 154; Arteriosclerosis, 158. 

CHAPTER X. 

Diseases of the Lungs and Pleueae 163 

Acute Bronchitis, 163; Chronic Bronchitis,, 167; Bronchi- 
ectasis, 172; Bronchial Asthma, 175; Edema of the Lungs, 
179; Lobar Pneumonia, 181; Broncho-Pneumonia (Lobu- 
lar Pneumonia), 190; Chronic Interstitial Pneumonia, 
194; Emphysema, 196; Pulmonary Gangrene, 197; Pul- 
monary Tuberculosis, 199; Acute Pleurisy, 211. 

CHAPTER XL 

Infectious Diseases 216 

Typhoid (Enteric Fever), 216; Bacillary Dysentery, 227; 
Amebic Dysentery, 231; Measles^ 233; Scarlet Fever 
(Scarlatina), 236; Malaria, 243; Diphtheria, 251; Rheu- 
matic Fever (Inflammatory Rheumatism), 255. 

CHAPTER XII. 

Constitutional Diseases 260 

Arthritis Deformans, 260; Gout, 263; Diabetes Mellitus, 267 

CHAPTER XIII. 

General Considerations > M . >. . . 272 

Physician and Patient, 272. 



GOLDEN RULES 

OF 

DIAGNOSIS AND TREATMENT 
OF DISEASES. 



CHAPTER I. 

DISEASES OF THE STOMACH. 

Gastric Ulcer. 

Remember that, while the tripod pain, vomiting, 
and hematemesis are somewhat characteristic of 
peptic nicer, they possess certain peculiarities. 
The pain of nicer is localized in a circumscribed 
area in the epigastrium, and radiates to the back at 
about the tenth dorsal vertebra. Tenderness is 
found over the area of pain. 

Remember that the pain occurs paroxysmally 
when food is taken and digestion is at its height, 
produced by irritation of acid gastric juice and the 
peristalsis. 

Emptying the stomach, either by vomiting or with 
stomach tube, relieves pain. Many patients will 
produce emesis to get relief. 

Remember that vomiting is rarely absent and oc- 
curs at the height of pain; and when the stomach is 
emptied, vomiting ceases and the pain is relieved. 

9 



10 DISEASES OF THE STOMACH. 

Hydrochloric acid is always present in vomitus of 
nicer, and frequently is excessive. 

Remember that copious, free hemorrhage is far 
more common in nicer than in any other disease of 
the stomach. 

Remember that profuse, painless, sudden hema- 
temesis in an elderly patient suggests hepatic 
cirrhosis rather than gastric ulcer. 

Dilatation occurs after the ulcer heals. It occurs 
only when the ulcer is near the pyloric opening and 
the contracting scar tissue partially closes it. 

Don't mistake the anemia of ulcer for malignant 
cachexia. 

Remember that the vomiting of bright-red blood 
is almost positive evidence of ulcer. 

Remember that the first symptom of ulcer may be 
perforation or a fatal hemorrhage. 

The area of tenderness in ulcer is about two 
inches below the ensiform cartilage and a little to 
the right of the median line. 

Remember that the pain of ulcer may be referred 
to the lower intercostal nerves, or axillary plexus, 
or down the arm. 

Pain may persist after the ulcer heals, caused by 
nerve filaments being caught and compressed in 
contracting and hardening of the scar tissue. 

Remember that ulcer is twice as frequent in 
women, and occurs between the fifteenth and 
twenty-fifth years. 

Remember that the pain of gastralgia is diffuse, 



GASTRIC ULCER. 11 

and pressure or food relieves it, and neither hema- 
temesis nor anemia occur. 

Remember that in the pain of gallstones the liver 
is enlarged and tender, and that jaundice and pal- 
pable gallbladder is frequently present. 

Always examine the stools, as frequently they 
contain blood, either macroscopic or occult, when 
the vomitus does not. 

Remember that the appetite is good in ulcer, but 
vomiting prevents digestion and nutrition is re- 
duced; hence these patients lose in weight. 

Remember that perforation is announced by sud- 
den, sharp, lancinating pain; weak, rapid pulse; 
shallow, hurried breathing, and cold, clammy sweat, 
with muscular rigidity and tenderness over the ab- 
domen. 

Remember that surgery is imperatively indicated 
in the early hours of perforation, before peritonitis 
develops. It is the importance of early surgical in- 
tervention that demands careful watchfulness on 
the part of the physician. It is gross ignorance or 
criminal carelessness to wait until peritonitis begins. 

Remember that passing a stomach tube may cause 
rupture at site of ulcer. 

Treatment. 

Remember that there must be mechanical as well 
as functional rest of the stomach, and the only way 
to obtain it is to keep the patient in bed. 

Remember that thirty-six hours of fasting, ex- 



12 DISEASES OF THE STOMACH. 

eluding even water, is the very best way to begin 
the treatment, unless the patient is greatly ema- 
ciated or old. 

Eelieve thirst with salt solution enemata. 

Begin rectal feeding at the end of thirty-six hours. 
Nutrient enamata during the fasting period will 
stimulate reflexly the gastric secretion, and this will 
irritate the ulcer and cause pain. 

Remember that the rectum has no digesting 
power; hence all foods must be ready for absorption. 

Predigested milk, to which is added one raw egg } 
makes an excellent enema. Don't give too large a 
quantity at a time, or it will be expelled. Four 
ounces, repeated every four hours, is best. 

Remember that panopepton is excellent in rectal 
feeding. Add it to normal salt solution. It is also 
excellent to begin feeding by mouth. 

Don't feed per rectum too long, as the bowel be- 
comes irritated and will not retain the enema. Feed 
per rectum exclusively for live days and then give 
some food by mouth. Two ounces of milk every 
three hours, with careful watching for return of 
pain, and, when absent, gradually increase the 
amount, is a good plan. At the end of the second 
week add meat broth, mashed potatoes, and white 
meat of fowl. 

The medicinal treatment is important, but not so 
effective when the dietetic regimen is omitted. 

The following prescription and method of admin- 
istering it give good results: 



GASTRIC ULCER 13 

1$ Bismuthi subnitratis 3 ij-3 v 

Aquae B i j 

Misce. 

Sig.: Give at one dose, with patient in the recumbent 
posture. Have the patient move from dorsal to side posi- 
tion slowly, then to the other side, thus allowing the bis- 
muth to coat the mucosa. 

Or: 

Ifc Cerrii oxalatis gr. i j 

Magnesii carbonatis levis gr. x 

Bismuthi subcarbonatis gr. xx 

Misce et fiat pulvere No. I. 

Sig.: Powder from three to six times daily. 

Iron may be added to the above if anemia be se- 
vere. This will relieve vomiting and is antacid. 

Or: 

B Resorcinolis (Merck) 3 j 

Argenti nitratis gr. vj 

Extracti hyoscyaminae gr. xxx 

Misce et fiant pilulse No. XXIV. 

Sig.: Pill three times daily one hour before meals. 

Astringent, antiseptic, and relieves pain. 
Or: 

I£ Argenti nitratis gr. vj 

Extracti belladonnas gr. v 

Extracti hyoscyaminae gr. xx 

Extracti gentianae q. s. 

Misce et fiant pilulae No. XXIV. 

Sig.: Pill one hour before meals. 

This is an excellent combination — astringent and 
tonic. 

Silver nitrate may be given in solution, either 
gr. % or solution 1 :1000 can be made and gradually 
increase dosage. Ortner's prescription is good. 



14 DISEASES OF THE STOMACH. 

IJ Extracti belladonnse gr. viiss 

Bismuthi subnitratis, 

Magnesii oxidi, 

Sodii bicarbonatis aa 3 iiss 

Misce et fiant pulveres. 

Sig.: A good pinch three times daily after eating. (Ortner.) 

For hematemesis, complete rest, and best obtained 
by hypodermic of morphin and atropin. Ice bag 
to epigastrium. If severe, bandage extremities and 
raise foot of bed. Eeplace lost fluid with normal 
salt solution, either in rectum or into cellular tissue, 
by hypodermoclysis. 

Ortner now gives 10 drams hypodermatically of 
Merck's 10-percent gelatin solution as long as blood 
may be seen in vomitus or stools. 

Tincture of the chloride of iron 5 to 15 drops every 
two hours is recommended. 

fy Stypticini ( Merck ) gr. x 

Antipyrini . . gr. xl 

Elixiris simplicis 3 j 

Misce et fiat solutio. 

Sig.: Teaspoonful in water every two or three hours as 
needed. 

Or: 

B Acidi tannici 3 ij 

Pulveres aluminis 3 j 

Garantose gr. ss 

Misce et fiant pulveres No. XVI. 

Sig. : 2 powders every fifteen minutes, followed by water. 

Where the cicatricial tissue causes obstruction at 
the pylorus, thiosinamin may be used to cause ab- 
sorption. 



GASTRIC ULCER GASTRIC CANCER. 15 

Ifc Thiosinamini 3 j 

Glycerini 3 ii j 

Alcoholis diluti 3 vj 

Misce et fiat solutio. 

Sig.: Inject 8 to 15 minims subcutaneously every two or 
three days. 

Gastric Cancer. 

Remember that cancer of the stomach is on the 
increase. A large majority of the cases occur be- 
tween the fortieth and seventieth years, but it is fre- 
quently found in young adults and even children. 

Remember that enlarged and painless cervical or 
inguinal lymph glands found in a dyspeptic past 
midlife strongly indicate cancer. 

Nodular swellings found under the skin about the 
navel or between it and the costal arch are meta- 
static cancer growths. 

Remember that many cancer patients have edema 
about the ankles or anasarca. This condition de- 
velops toward the close and is due to debility. 

In cancer the vomiting frequently occurs late in 
the day or during the night, with insomnia. Fre- 
quently insomnia is the most troublesome symptom. 

Remember that a tumor can be palpated in three- 
fourths of the cases. 

Remember that a gastric tumor can be moved to 
any part of the abdomen, or even into the pelvis. 

Remember that a tumor that moves with respira- 
tion, but has neither respiratory fixation nor lateral 
movements, is not gastric, but hepatic. 

Remember that hydrochloric acid is absent or 



16 DISEASES OF THE STOMACH. 

greatly diminished, and lactic acid is present and 
Boas-Oppler bacillns may be fonnd. 

Always examine gastric contents, and better give 
test meal. 

Remember that in palpating a gastric tumor three 
things are fonnd: 

1. Changes on deep inspiration, but is free from 
respiratory movements. * 

2. Wide area of aortic pulsation. 

3. Intrinsic movements occurring in the contrac- 
tion of the hypertrophied muscularis of the tumor, 
causing it to appear and disappear, lifting the ab- 
dominal wall overlying the tumor. 

Remember the value of inspection and observe — 

1. The state of general nutrition. 

2. Fullness in the epigastrium. 

3. Peristaltic waves. 

4. Nodules under the skin. 

Remember that the pain of carcinoma is constant 
and gnawing, not often referred, and vomiting af- 
fords no relief. 

Remember that fatty stools, uncontrollable 
diarrhea, glycosuria, and perhaps the palpation of 
an immovable tumor are signs of pancreatic cancer. 

Remember that emaciation, loss of weight and 
strength, vomiting of coffee-ground colored ma- 
terial, and cachexia, with presence of gastric tumor, 
leaves little doubt of cancer. As a rule there is no 
vomiting of bright-red blood or clots, that are fre- 
quently associated with peptic ulcer. 



GASTRIC CANCER. 17 

Remember that the duration is short, seldom ex- 
ceeding one year. 

Treatment. 

Surgery offers the only hope, and the diagnosis 
must be made early if an operation be of any benefit. 

Remember that, medicinally, the object sought is 
relief of pain and vomiting. Tonics should be given. 

Washing out the stomach often relieves pain and 
vomiting. Use saline solution or boracic acid solu- 
tion. Condurango bark, given in powder of 30 
grains each three times daily, gives excellent re- 
sults as to the amelioration of symptoms and im- 
provement of appetite. 

Elixiris ferri quininae et strychninse (U. S. P.) 
3 ij, three times daily after meals. 

Liquoris potassii arsenitis ttl iij vel iTt v is not 
only a good tonic, but is very beneficial in fighting 
the anemia. 

Where pain is due to superacidity, the following 
relieves by neutralizing the acid: 

Ifc Sodii bicarbonatis gr. xv vel gr. xx 

Magnesii carbonatis gr. v vel gr. x 

Acidi hydrocyanici diluti HI iv 

Aquae menthse piperita^ . . . . q. s. ad t j 

Misce. 

Sig. : To be taken at one dose and repeat three times 
daily. 

Creosote in minim doses in gelatin capsule after 
food is very highly praised by Yeo. He says espe- 
cially good results are obtained in the scirrhus form 
of cancer. 



18 DISEASES OF THE STOMACH. 

B Dionini gr. viij 

Acidi hydrocyanici diluti Til xxx 

Bismuthi subnitratis 3 ij 

Aquae ehloroformi q. s. ad £ iv 

Misce et fiat solutio. 

Sig. : Shake well and take teaspoonful every two or three 
hours. 

Or: 

B Resorcinolis (Merck) gr. xxx 

Vini rhei 3 j 

Syrupi aurantii 3 iv 

Decoctionis condurango ( 1 : 12 ) q. s. ad § vj 
Misce et fiat solutio. Dispense in dark amber bottles. 
Sig. : Tablespoonful every two hours. 

Gastritis. 

Remember that the history of the case, especially 
that relating to the diet, will be of great help in 
diagnosis. Usually find excess at the table, the eat- 
ing of tainted food or overripe fruit. 

Remember that a majority of the cases are 
afebrile, and recovery in forty-eight hours is the 
rule, except where the attack is due to toxic sub- 
stances contained in the food. 

Always test the knee jerk and reaction of the 
pupil, because gastric crisis occurring in locomotor 
ataxia frequently simulates acute gastritis. 

Remember that a severe case may require time to 
clear up the diagnosis. For instance, an attack ac- 
companied by severe headache and delirium occur- 
ring in a child might be mistaken for meningitis, or 
the pain may be so severe as to suggest gallstones, 
and frequently it marks the onset of many of the 



GASTRITIS. 19 

infectious diseases, as measles, scarlatina, and ty- 
phoid. 

Always examine the heart, liver, and lungs in all 
cases of chronic gastric catarrh, as it is often due 
to portal stasis. 

Remember that the vomiting of mucus, or where 
the gastric contents are thickly coated with mucus, 
is found only in catarrhal processes. 

Remember that alcohol is an important factor in 
causing chronic gastritis, and it must be discon- 
tinued if treatment be of any avail. 

Many cases of cardiac palpitation or dyspnea are 
due to gastritis, causing the food to ferment and the 
gas distends the stomach. 

Treatment. 

In an acute attack allow no food for twenty-four 
hours. Stimulate vomiting by giving a tumbler of 
warm salt water and repeat until the stomach is 
thoroughly cleansed. If water checks the vomiting 
by diluting the irritant, produce it by tickling the 
fauces. Use the stomach tube if possible and wash 
out thoroughly. Follow with a cathartic. 

Olei recini §j, given in orange juice, with 2 or 
3 drops of tincturae opii if needed, is excellent. 

If icterus develops, or vomiting persists, give the 
following : 

T$ Hydrargyri chloridi mitis gr. iv 

Cerrii oxalitis gr. x 

Sacchari lactis gr. xxx 

Misce et fiant pulveres No. XII. 

Sig. : Powder dry on tongue every fifteen minutes. 



20 DISEASES OF THE STOMACH. 

Two hours after last powder give saline. A mus- 
tard plaster over the epigastrium gives relief. 

For continued nausea allow cracked ice. Follow 
with a liquid diet, preferably milk, to which add 
lime water or soda water. Allow a wineglassful 
every three or four hours. After cleansing the 
stomach a sedative is indicated and bismuth is the 
best. 

B Bismuthi carbonatis, 

Sodii bicarbonatis aa 3 i j 

Spiritus chloroformi 3 j 

Aquae menthae piperita^ . . . . q. s. ad £ iij 
Misce et fiat solutio. 
Sig.: Tablespoonful every four hours. 

If the pain is severe, the deodorized tincture of 
opium may be added to the above. Later a bitter 
tonic may be needed. The following is good: 

Ifc Tineturse nucis vomicae 3 ij 

Tincturae gentianae compositae 3 iss 

Tineturse cinchona? compositae q.s.ad^iv 
Misce et fiat solutio. 
Sig.: Teaspoonful before meals. 

Dilute muriatic or nitromuriatic acid may be 
added if needed. In chronic cases remove the cause, 
if possible. If due to alcohol or iced drinks, prohibit 
them. If secondary to cardiac, hepatic, or pul- 
monary conditions, relief will follow improvement 
in those conditions. It is in the chronic form that 
stomach washing gives the most brilliant results. 

After a thorough washing with clear water, the 
following solution may be run into the stomach as 
a final douche: 



GASTRITIS. 21 

IJ Thymol gr. vii j 

Acidi borici 3 iv 

Aquae O j 

Misce et fiat solutio. 

Sig. : Use in stomach tube. 

If the tube can not be used, have the patient 
drink a pint of hot water in which is dissolved a 
half dram of sodium bicarbonate on arising in the 
morning. This will dissolve the mucus, and thus 
cleanse the gastric mucosa as well as stimulate the 
circulation. Direct patient to take meal without 
liquids. This insures thorough mastication and in- 
salivation. Diet should be light and nutritious. A 
glass of milk containing a raw egg y given twice a 
day between meals, is excellent. If dilatation exists, 
give dry diet and small quantity every four hours, 
and wash out stomach once a day. 

For sour eructations and distention of stomach by 
gas the following is excellent: 

IJ Phenolis gr. xxv 

Glycerini 3 iv 

Bismuthi subcarbonatis 3 v 

Lactis magnesiee q. s. ad % iij 

Misce. 

Sig.: Shake well and take teaspoonful after food. 

The following before meals gives good results: 

Ifc Resorcinolis ( Merck ) 3 j 

Bismuthi salicylatis 3 iiss 

Tincturse catechu 3 v j 

Syrupi aurantii 3 i j 

Aquae q. s. ad 5 iv 

Misce. 

Sig.: Shake and take dessertspoonful half hour before 
meals. 



22 DISEASES OF THE STOMACH. 

Where neurasthenia coexists : 

B Arseni trioxidi gr. j 

Extracti nucis vomicae gr. x 

Euquinini (Merck) gr. xxx 

Ferri carbonatis 3 ij 

Mucilaginis acacias q. s. 

Misce et fiant pilulae No. LX. 
Sig. : 2 pills after meals. 

Hyperchlorhydria. 

Remember that under this term is included a con- 
dition of excessive formation of hydrochloric acid, 
due entirely to nervous influence, and no anatomical 
lesion is found; hence it is quite common in chloro- 
sis, hysteria, and neurasthenia. It is frequently 
found in brainworkers. 

Pain is variable, from mild discomfort after meals 
to an intense gastralgia, developing at the height 
of digestion and caused by the presence of free 
hydrochloric acid. Vomiting or eating of proteid 
food will relieve the pain, because it removes the 
acid. 

Eructation, heartburn, increased salivation, and 
vomiting of sour liquid occurs. 

Remember that there is no " tender spot" or 
hematemesis as seen in ulcer. 

Remember that the absence of excess of mucus 
and excess of HC1 with the history excludes gas- 
tritis. 

Examination of stomach contents shows HC1, no 
lactic acid or Oppler-Boas bacilli, and the duration 
of disease will exclude cancer. 



HYPERCHLORHYDRIA. 23 

Remember that this condition occurs in children, 
and usually presents the following picture : a highly 
neurotic child is attacked at midday by severe head- 
ache, causing it to cry out with pain, increased by 
moving the head, or by coughing or sneezing; next 
a violent pain in the stomach, with legs drawn up, 
hands clasped over the stomach; belching of gas 
and sudden emesis, without apparent effort, which 
gives relief. The vomitus is pale-green or yellow 
color, fluid, and contains an excess of HC1. It will 
digest egg albumen. Usually a rise of temperature 
at onset, but later becomes subnormal. Tongue is 
clear, moist, and red. 

Treatment. 

Diet. Milk and egg diet for a few days often 
relieves milder forms. Proteid diet is indicated, as 
it uses up the acid. Carbohydrates should be greatly 
restricted. Don't allow wines, liquors, tobacco, con- 
diments, smoked" meat, sour foods, or radishes. 

Lavage. Washing out the stomach, preferably 
in the evening, with an alkaline solution or a solu- 
tion of silver nitrate (1:1000) gives excellent results. 

Medication. Alkalies, especially the earthy, are 
indicated. 

The following is a good antacid : 

Rv Sodii carbonatis, 

Magnesii carbonatis, 

Bismuthi subcarbonatis aa gr. xv 

Misce et fiat pulvere No. I. Dentur tales No. XX. 
Sig. : Powder two or three hours after meals. 



24 DISEASES OF THE STOMACH. 

To check secretion use belladonna or atropin: 

B Extracti belladonnae gr. y s 

Magnesii oxidi gr. x 

Misce et fiat pulvere No. I. Dentur tales No. XX. 
Sig.: Powder after meals. 

If fermentation occurs, with ernctation of gas: 

I£ Phenolis gr. xxv 

Glycerini 3 i j 

Bismuthi subcarbonatis 3 iv 

Lactis magnesiae q. s. ad g iij 

Misce et fiat solutio. 

Sig. : Shake well and take a teaspoonful after meals. 

Or: 

B Argenti nitratis . . . ; gr. iij 

Aquae destillatae 3 iij 

Misce et fiat solutio. 

Sig.: Dessertspoonful two hours after meals. 

Distress after meals may be relieved by: 

IJ Creosoti TU xv 

Sodii bicarbonatis gr. xxx 

Spiritus chloroformi, 

Spiritus ammonii aromatici . . . . aa 3 ss 

Aquas menthse piperitae . . . . q. s. ad g iij 
Misce et fiat solutio. 
Sig.: Dessertspoonful after meals. 

For the nervousness give: 

B Sodii bromidi 3 j 

Eesorcinolis ( Merck ) gr. xxv 

Aquae anisi q. s. ad % iij 

Misce et fiat solutio. 

Sig.: Dessertspoonful after meals. 

Hematemesis. 

Remember that fatal syncope may occur without 
any vomiting. The blood vomited may be fluid or 
clotted, and is usually dark in color. Anemia and 



HEMATEMESIS. 25 

edema develop early, and convulsions, hemiplegia, 
or blindness may occur. 

Remember that gastric hemorrhage may be the 
first symptom observed in leukemia. 

Remember that fatal hemorrhage may be due to 
rupture of varix in esophagus, and blood run into 
the stomach; hence no gastric lesion is found. 

Remember that the blood is vomited if it comes 
from the stomach, while it comes up from the lungs 
after a fit of coughing; as a rule, blood from the 
lungs is free of clots, or, if any, they are small. The 
blood is frothy, because of the contained air and 
alkaline in reaction. 

Treatment. 

Absolute quiet in bed. Nothing by mouth, except 
cracked ice. Morphin and atropin hypo derma tically 
to effect. Ergot or ergotin hypodermatically. Give 
10 drams of Merck's gelatin, 10-percent, sterilized, 
and repeat as long as blood appears in vomit or 
stools. Ice bag over epigastric region. Feed only 
per rectum. 

Tincturae ferri chloridi in 5 to 15 drops may be 
given. Plumbi acetatis gr. ss-gr. j may be given 
every two hours. If severe or oft repeated, opera- 
tion is indicated if the patient's condition is good. 

Most cases recover quickly with rest, and styptics 
per os may cause vomiting. Hypodermoclysis of 
normal saline solution or transfusion by Crile's 
method may be life-saving. 



CHAPTER II. 

DISEASES OF THE INTESTINES. 

Acute Enteritis. 

Remember that exposure to cold or sudden and 
decisive drop in the temperature may cause an 
enteritis, probably due to influence on cutaneous 
nerves. Improper food, especially in children, is 
a very frequent cause. 

There is no question that some cases are due to 
malaria, and quinin readily controls the diarrhea 
when other remedies fail. 

The dominant symptom is diarrhea. The stools 
are thin, mushy, or watery, and pale-yellow or 
greenish color, and contain mucus, but rarely any 
blood. In severe form stools lose color, assume the 
rice-water character, are foamy, and have sour odor. 
With the microscope portions of undigested food, 
mucus, bacteria, epithelial cells, and calcium oxalate 
and phosphate crystals may be seen. 

Colic is often present. The severity of the pain 
varies, and may cause collapse. Pressure over the 
abdomen affords relief. Abdominal distention and 
borborygmi occur, due to gas formation. Great 
thirst and diminution of quantity of urine occur 
from loss of water by the bowel. In severe cases 
urinary suppression occurs, followed by general 
edema. Albumins and casts may be found in the 

26 



ACUTE ENTERITIS. 27 

urine. Skin may be cyanotic, cold, and clammy. 
Emaciation is rapid in children, and eyes become 
sunken. Fever may occur, but is usually absent. 
Remember that, in case fever is present, it lacks 
the peculiar curve and persistency found in typhoid, 
and the absence of slow pulse; the enlarged spleen 
and the absence of eruption would also exclude 
typhoid. 

Etiologic Treatment. 

If pain be severe, give hypodermic of morphin 
and atropin. If due to cold, give sudorifics and ex- 
ternal applications to produce sweating. Where ma- 
laria is cause, give quinin. If due to chemical poi- 
sons that can be neutralized, give the proper anti- 
dote. 

If caused by toxins that can not be neutralized, 
too coarse food, or impacted feces, rid the bowel as 
soon as possible of irritating substances. 

Cathartics. We have two means of cleansing the 
bowel — drugs and colon irrigation. Owing to the 
inflammatory condition, only mild drugs should be 
given. Castor oil or calomel is best. 

Castor oil should be administered in one large 
dose, % ounce in orange juice, to which may be 
added a few drops of tincture of opium to prevent 
griping. 

Calomel is especially indicated in persistent 
vomiting. Best to give one large dose — gr. iv-gr. vij 
— as small repeated doses may irritate the bowel. 



28 DISEASES OF THE INTESTINES. 

Colon irrigation is the least harmful. Use 1 quart 
of warm water, and, to assist in retaining it, add 20 
drops of the tincture of opium. Soap, glycerin, or 
oil may be used in the water. 

Diet is important. Reduce the work of the bowel 
to the minimum by using concentrated diet, with 
little residue. Complete abstinence for twenty-four 
hours, with teaspoonful of tea for the thirst, is ex- 
cellent. Allow only gruels from barley, rice, sago, 
or arrow-root. Give one or two tablespoonfuls 
hourly. Albumen water is allowable. Of liquids, 
tea is best, given tepid or hot. As the diarrhea 
decreases give broths, with yolk of egg, crackers, 
and breadcrusts. During the attack give food in 
small quantities, neither very hot nor cold. Milk 
may be tried by giving a tepid tablespoonful hourly, 
and, if it increases the diarrhea, stop it. 

Medication should be such as meets the indica- 
tions. Soft capsule of olei ricini nx x-ir\, xx and salol 
gr. v are very efficacious. Or creosote may be used as 
follows : 

B Creosoti TTt xv 

Tincturae gentianse composite TTt xxx 

Spiritus vim gallici 3 iij 

Misce. 

Sig.: Teaspoonful three times daily. 

Or: 

B Bismuthi benzoatis 9 ij 

Salolis gr. xxiv 

Pulveris opii gr. vj 

Misce et fiant pulveres No. VIII. 

Sig.: Powder every three or four hours after the bowels 
have first been cleansed of irritating material. 



ACUTE ENTERITIS. 29 



Or: 



IJ Tannalbini 3 ij 

Resorcinolis ( Merck ) gr. xv 

Glycerini 3 j 

Aquse cinnamomi q. s. ad 3 iv 

Misce fiat mistura?. 

Sig. : Shake well and take a dessertspoonful every three 
hours. For adult a tablespoonful should be given. 

For relief of thirst and to replace the fluid lost 
by the body, the continual seepage of normal saline 
solution into the bowel is excellent. The technic of 
continuous flow is very important and is as follows: 
a fountain syringe, or a can with a large rubber 
tube attached, and a hard-rubber vaginal tip, with 
several openings at the end, is all that is required. 
Flex the vaginal tip about two inches from the end 
by placing it in hot water and bending it, thus 
forming an obtuse angle. Insert until the angle fits 
closely to the sphincter, then bind the tube to the 
thigh with strips of adhesive to prevent its being 
expelled. The douche bag or can is suspended from 
the foot of the bed so that its base is six inches 
above the level of the patient's buttocks. Put one 
and a half pints of solution in the bag at a tem- 
perature of 100° and keep it at this tempera- 
ture. It should require no less than forty nor more 
than sixty minutes for this amount to percolate 
into the bowel. If administered more rapidly, it 
will be expelled. A hypodermoclysis of normal sa- 
line solution into the subcutaneous tissue may be 
resorted to in desperate cases. 



30 DISEASES OF THE INTESTINES. 

Chronic Enteritis. 

Remember that constipation is the rule in the 
chronic, but may alternate with diarrhea. 

Always examine the stools, as they contain the 
diagnostic evidence. 

Remember that mucus in the stools is always in- 
dicative of enteritis, and never occurs from ulcer or 
cancer alone; but the presence of blood always signi- 
fies a complication, such as piles, ulcer, or cancer. 
Undigested portions of meats, fats, and starch may 
be abundant. 

1 'Sago-pearls' ' are swollen, glassy particles of 
mucus, and may be seen in the stool. Yellow mucus 
granules are soft particles of mucus stained by bile 
pigment, and originate in the small bowel. Colicky 
pains over lower portion of abdomen, tenesmus, and 
gaseous distention are often present. Where colitis 
exists, tenderness over the course of the colon may 
be elicited by palpation. There is pallor and loss 
of flesh. 

Teeatment. 

The diet is of great importance. It must be 
nourishing, so that the patient's strength is built 
up and yet avoid irritating the bowel. Meats suit- 
able are white meat and fish, scraped beef, calves' 
brains, chopped meats. Broths, eggs — raw, soft 
boiled, or scrambled — may be added. Farinaceous 
foods. Broths are liable to irritate, and, when 
given, the vegetables and meat should be strained 



CHRONIC ENTERITIS. 31 

out. Rice, sago, and arrow-root are good. Milk is 
excellent; one to two quarts daily; add lime water if 
it causes any trouble. Fats — only form is butter. 
Fresh fruit should be entirely forbidden. 

Time. Meals should be given five times a day. 

The stools should be watched for particles of 
undigested food or milk curds. 

Colonic irrigation is best if the large bowel is in- 
volved. May use warm water, saline solution, or 
olive oil. Castor oil or calomel is best laxative, and 
should be given in one dose to prevent irritation of 
mucosa. Astringents may be needed to control the 
diarrhea; these may be added to irrigation solution, 
using tannin 1 dram to the quart, or boracic acid 
5:1000, or silver nitrate 1:2000. 

Medication. Tannigen and tannalbin are excel- 
lent astringents. They are tasteless, and are not 
affected by gastric juice. 

Ifc Tannalbini gr. xv 

Fiat capsula No. I. Dentur tales capsular No. XXX. 
Sig.: 4 to 6 capsules daily. 

Or: 

IJ Tannigeni gr. vi j 

Fiat capsula No. I. Dentur tales capsular No. XX. 
Sig.: Capsule every two hours. 

Alum gr. iss-gr. iv may be given every two hours. 
Lead acetate gr. ss-gr. iss may be administered. 
Silver nitrate internally is not efficacious, as hydro- 
chloric acid in the stomach converts it into the chlo- 
rid; when used, it should be given in capsules hard- 
ened with formalin, so that the gastric juice will 



32 DISEASES OF THE INTESTINES. 

have no effect. Bismuth is excellent; use either 
subnitrate or salicylate in large doses. 

B Bismuthi subnitratis gr. xx-gr. xxv 

Extracti opii gr. i^-gr. y s 

Misce et fiat pulvere No. I. Dentur tales doses No. XXX. 
Sig. : Powder every two or three hours. 

Or: 

Ifc Bismuthi subnitratis gr. xxx 

Bismuthi subgallatis gr. x 

Misce et fiat charta No. I. Dentur tales chartse No. X. 
Sig.: Powder every two or three hours. 

Or: 

1$ Plumbi acetatis 9 j 

Extracti opii 9 ss 

Kesorcinolis (Merck) 9 iss 

Misce et fiant capsular No. X. 

Sig.: Capsule every three hours. 

Or: 

B Salolis 3j 

Sodii bicarbonatis, 

Sodii benzoatis, 

Bismuthi salicylatis aa 3 iss 

Misce et fiant pulveres No. XX. 
Sig.: Powder every four hours. 

Obstruction of the Bowel. 

Remember that the symptom complex will vary 
according to the degree of obstruction. There may 
be slight difficulty in the discharge of feces, or fecal 
retention may occur, and onset may be sudden or 
gradual. 

Accumulation of feces and gases occurs above 
constricted area. Distention of abdomen. Peristal- 



OBSTRUCTION OF BOWEL. 33 

tic waves can be seen above obstruction. In complete 
obstruction there are great distention, collapse, 
feeble pulse, coldness, and cyanosis of the extremi- 
ties. Vomiting, at first greenish, later resembles 
feces and has a fecal odor. 

Intussusception. 

Remember that it most often occurs at iliocecal 
junction, and usually found in infancy. 

1. Sudden onset of pain — severe, continuous, or 
paroxysmal; referred to umbilicus. 

2. Vomiting occurs early. More constant in chil- 
dren. Rarely have fecal vomiting in children. 

3. Stools are characteristic, containing blood and 
mucus. Tenesmus is severe. 

4. Tumor is egg or sausage-shaped, movable, and 
firm. It changes its position as the intussusception 
progresses. Treves says, "It nearly always can be 
felt during pain. ' ' Clubbe says, ' ' Very sudden onset 
in previously healthy baby is a peculiarity of intus- 
susception. The child screams, turns pale, vomits, 
which ceases but to recur again.' ' 

5. Pulse and temperature remain normal. 
Issue. May terminate in one of three ways: 

1. Union at the point of invagination, with 
sloughing of the invaginated portion of the gut, and 
recovery. (Rare.) 

2. Peritonitis. 

3. Ulceration and perforation. 



34 diseases of the intestines. 

Teeatment. 

Never administer cathartics and purgatives, even 
in fecal impaction. Enemata of water or saline solu- 
tion witli rectal tube, with hips of the patient ele- 
vated, is best. If an intussusception is seen early, 
the distention of the bowel with either air or water 
may reduce it; but if the invaginated portion be- 
comes edematous, it will be of no avail. 

Remember that it is a safe rule to operate in in- 
testinal obstruction of any cause other than fecal 
impaction, and do it early before peritonitis sets in. 

Remember that obstruction of the bowel due to 
fecal accumulation is positively the only form that 
does not belong to the surgeon. 

Chronic Constipation. 

Remember that persistent constipation, continu- 
ing for weeks, is incompatible with good health. 

Remember that constipation is a relative term. 
Autointoxication is supposed to be the cause of a 
great many ills due to the resorption of noxious mat- 
ter from retained feces. 

Remember that the fecal mass may become chan- 
neled and diarrhea occur. An habitually consti- 
pated woman, seized with diarrhea, nausea, and 
vomiting, should cause a thorough examination of 
the large bowel. 

Remember that dysmenorrhea and sacral neural- 
gia may be caused by impacted feces. Piles, colonic 
ulceration, occlusion of the bowel, and perforation 



CHRONIC CONSTIPATION. 35 



may be caused by persistent retention. As a rule, 
mental depression, lassitude, headache, coated 
tongue, and anorexia are the more common symp- 
toms. Attack of colic may occur. 

Treatment. 

Diet is very important. Coarse foods, as whole 
wheat, rye, or cornmeal bread. Fruits, except ba- 
nanas. Vegetables, as cabbage, turnips, tomatoes, 
spinach, onions, celery. Sweets, if they do not cause 
indigestion, are laxative. Fats, as butter and olive 
oil. Water freely during the day; a glass of water 
at night or morning acts beneficially. Punctuality 
at the stools must be urged; best time is after break- 
fast. 

Massage will relieve if continued for a long period 
of time. The hand should be placed over the cecum 
and follow the course of the colon. This is contra- 
indicated in spastic constipation. Exercise of the 
body in tennis, rowing, lifting the legs while lying 
on the back, walking. 

Enemata will stimulate peristalsis and lessen con- 
gestion. Overdistention produces colonic dilata- 
tion; hence, in time, they lose their beneficial effects. 

Drugs. Aloes and strychnin are indicated. 

Ifc Extracti aloes gr. ss 

Extracti rhei gr. ij-gr. v 

Extracti nucis vomicae gr. ^ 

Resinae podophylli gr. i^ 

Extracti belladonna? gr. 14 

Extracti taraxaci gr. j 

Misce et fiat pilula No. I. 

Sig. : Pill night and morning. Not to be given in preg- 
nancy. 



36 DISEASES OF THE INTESTINES. 

Or: 

IJ Extracti belladonnae gr. y& 

Extracti nucis vomicae gr. % 

Extracti colocynthidis gr. ij 

Misce et fiat pilula No. I. 

Sig.: Pill three times daily. 

In atony of the bowel use: 

IJ Extracti rhamni purshianae 3 j 

Extracti nucis vomicae gr. viij 

Extracti physostigmatis gr. ij 

Extracti hyoscyaminae : . gr. v 

Misce et fiant pilulae No. XXX. 

Sig.: Pill night and morning. 

If anemic, add iron or use: 

IJ Ferri sulphatis gr. x 

Extracti aloes aquosi gr. v 

Extracti rhamni purshianae gr. xx 

Extracti belladonnae, 

Extracti nucis vomicae aa gr. iij 

Misce et fiant pilulae No. X. 
Sig.: Pill after meals. 

In old people use the following: 

IJ Aloini gr. vj 

Podophylli gr. ij 

Misce et fiant pilulae No. XII. 
Sig.: Pill night and morning. 

Phenolphthalein is good and causes no griping. 
It is the principal ingredient in recent proprietaries. 
It is not harmless, as collapse, with vomiting and 
diarrhea, have occurred with purgen. 

IJ Fluidextracti rhamni purshianae aro- 

matici 3 iv 

Sig.: Teaspoonful night and morning. The morning dose 
taken with a glass of hot water half an hour before break- 
fast. 



APPENDICITIS. 37 

Gradually withdraw drug as habit of daily evacu- 
ation is established. 

Appendicitis. 

Remember that the various forms described are 
only various stages in the progressive changes of 
one pathological condition, and that an unchecked 
inflammation of the appendix will terminate in gan- 
grene and death. Of all the inflammatory condi- 
tions in the abdomen occurring in persons under 
thirty, appendicitis is by far the most common. 

Remember that sudden pain in the right iliac 
fossa, fever, rigidity of right rectus muscle, and 
localized tenderness is appendicitis almost without 
a single exception. 

Remember that fecal vomiting, a very common 
symptom of obstruction, is never seen in appendi- 
citis. 

Remember that marked tenesmus and bloody 
stools in children are the signs of intussusception 
and not appendicitis. 

Remember that the thermometer is one of the 
most trustworthy guides in diagnosing appendicitis, 
and Murphy says he would refuse operation if no 
fever was present during the first thirty-six hours 
of the disease. 

Remember that the subsidence of excruciating 
pain is an ominous sign of gangrene, and perfora- 
tion is not far distant. 

Remember to exclude the onset of pneumonia in 



38 DISEASES OF THE INTESTINES. 

cases of sudden colicky pain in abdomen of children 
by auscultating the chest. 

Remember that typhoid bacilli may cause appen- 
dicitis and many cases of perforation occur through 
typhoid ulcer. 

Never mask your symptoms with morphin; it is 
positively suicidal for both doctor and patient. If 
the patient complains of pain in emptying the blad- 
der or rectum, always examine per rectum for recto- 
vesical or rectouterine tenderness, or an inflamma- 
tory swelling. 

Tenderness at the right side of the rectum in rec- 
tal examination is nearly always present, although 
there may be none at McBurney's point. 

Masked Appendicitis. 

In this form there is no history of an acute attack, 
and the usual clinical picture of appendicitis is 
absent. 

1. Dyspepsia, with belching, pain at irregular 
intervals following meals, persisting for a time, fol- 
lowed by a period of complete disappearance of all 
symptoms regardless of diet. 

2. Diarrhea, especially early morning, with two 
or three loose movements, with freedom from it for 
balance of the day. Evacuations may be preceded 
by colicky pains, which the evacuations relieve. 
At times there is a peculiar periodicity of diarrhea, 
occurring at a certain morning hour. There are 
periods of freedom from diarrhea, just as the 



APPENDICITIS. 39 

gastric symptoms. The stools may be normal at 
first, but later become slimy and contain mucus. 
Persistent constipation, with extreme neurosis, may 
occur. 

3. Pain is paroxysmal, with all degrees of sever- 
ity. Occurs suddenly, often in the epigastric region, 
accompanied by nausea and vomiting. 

4. Palpation over the appendicular area will usu- 
ally reveal tenderness and often causes nausea. The 
swollen appendix can be palpated through a re- 
laxed abdominal wall if not too thick. 

Remember that disease of the gallbladder, 
stomach, and pelvis must be excluded before mak- 
ing a positive diagnosis. Have the patient lie on the 
back and limbs straight. With the tips of the fingers 
over the cecum, make deep pressure. Now tell the 
patient to make the muscles of the right limb rigid 
and stiff at the knee, and raise the foot by using 
hip joint and lifting as against a weight. If the 
appendix is at all tender, he will complain of pain. 

Treatment. 

Remember that the treatment of appendicitis is 
always surgical, regardless of type, time, or tender- 
ness. The danger of perforation and general peri- 
tonitis occurring at any hour should always be kept 
in mind, and warn us against useless medication. 

If an operation is absolutely prohibited, then 
Oschner's method gives best results. Give abso- 
lutely nothing by mouth; use nutrient rectal ene- 



40 DISEASES OF THE INTESTINES. 

mata. If vomiting is present, wash out the stomach. 
Apply an ice bag over the cecum. Use continuous 
seepage (page 29) of normal saline. If pain is 
intense, use enough morphin to make it bearable, but 
never entirely relieve it. 

Mucous Colitis. 

Remember that this is a neurosis, and is found 
in hysterical or hypochondriacal patients. They are 
dyspeptics, and have carried self-dieting to such ex- 
tremes that they become thin and anemic. 

The diagnostic sign is mucus — either as strips, 
shreds, or casts — passed at stool. Other times it is 
a slimy, gelatinous mass, resembling frog-spawn. 
Usually occurs at intervals and follows prolonged 
constipation. Colicky pain, usually agonizing, with 
tenesmus, is present. These mucous segments are 
often mistaken for segments of tapeworm. 

There is tenderness over the colon, and often a 
spot of great tenderness between the navel and left 
costal arch. Abdomen is rarely distended. Mucous 
casts may be found in the urine. Urticaria and boils 
are frequently associated with this condition. 

Treatment. 

Plenty of outdoor exercise should be given. Diet 
must be liberal, and consist of the ordinary foods; 
should be well cooked and served at regular time. 
Foods leaving considerable residue are good to over- 
come constipation. 



MUCOUS COLITIS — VISCEROPTOSIS. 41 

Constipation is best prevented by castor oil. Give 
in morning on empty stomach and enough to open 
the bowel. Calomel or magnesium sulphate may be 
used, but are not so good. Pain can usually be re- 
lieved by hot applications to the abdomen, but at 
times it is so severe as to require hypodermic of 
morphin combined with atropin. 

Irrigate the colon with normal saline solution. 
In severe neurosis use the Weir-Mitchell method of 
feeding. Quiet the nervous condition with bromids. 

At night inject as high as possible half to a pint 
of warm olive or cottonseed oil. Have patient re- 
tain the oil all night if possible. This usually causes 
a copious evacuation in the morning. Continue this 
every night for two or three weeks, then every other 
night for same period, then three times a week. 

Arsenic and the glycerophosphates will often give 
excellent results. 

Visceroptosis. 

To determine the degree of displacement of the 
abdominal organs, accurately and easily applied sur- 
face markings of the normal position of the organs 
are essential. The following lines will be of aid : 

The sternoensiform line is drawn across the body 
at the junction of sternum and ensiform. It marks 
the height of the abdominal viscera. In the right 
nipple line, with patient in recumbent posture, 
hepatic dullness begins. Gastric resonance falls half 
an inch below it on left side; the central tendon of 



42 DISEASES OF THE INTESTINES. 

the diaphragm half an inch below in median line. 
In addition, this line indicates the kind and degree 
of chest deformity. It crosses the fifth costal on 
either side in normal chest, but may cnt the fifth 
space in emphysema because the ribs and cartilages 
are abnormally horizontal; or it may cnt the fourth 
space or fourth rib if the ribs are abnormally de- 
pressed, as they so often are in visceroptosis. 

The midepigastric point is midway between the 
umbilicus and the sternoensiform junction. 

The transpyloric line passes through this point. 
It cuts the costal margin near the outer border of 
the recti and crosses the ninth costal cartilage. 

The pylorus is situated on this line, halfway be- 
tween the midepigastric point and the costal mar- 
gin. In ptosis it is displaced downward and toward 
the median line. 

The lesser gastric curvature is about three-fourths 
of an inch above and the greater curvature one and 
one-half inches below the midepigastric point; this 
point marks the lower hepatic margin as it crosses 
the body, while behind it the pancreas crosses the 
spinal column. 

The umbilical line is drawn through the umbilicus 
and touches the iliac crests. 

The transverse colon lies just above it, while the 
lower poles of the kidneys do not reach it. In ptosis 
both colon and kidneys fall below this line. 

Symptoms. A high degree of ptosis may cause no 
symptoms. 



VISCEROPTOSIS. 4 



o 



1. Circulatory disturbances are manifested by diz- 
ziness, fainting, flushing of the head, and palpi- 
tation in the upright position, but relief is obtained 
on lying down. 

2. Gastric symptoms are anorexia, nausea, vom- 
iting, and eructations. 

3. Nervous group includes pain or dragging sen- 
sation in back or loins, neuralgic pains in the head, 
sleeplessness, despondency, and reflex cough. 

4. Intestinal — constipation is the rule, but diar- 
rhea is present if mucous colitis exists. 

Eespiration is costal, superficial, and apex beat 
of heart may be seen in sixth space, and visible tug 
on strictures at root of neck. Epigastric area sinks 
in, and hypogastric region protrudes in erect pos- 
ture. The skin is of grayish hue, and cold and 
clammy. Hands and feet readily become cold. The 
abdominal organs are displaced downward. The 
pancreas is palpable as a cord crossing spinal 
column. 

Treatment. 

Diet should be liberal, with a view of putting on 
fat, thus furnishing additional support to the viscera. 
Forced feeding on the Weir-Mitchell plan is excel- 
lent, because the nervous system improves in addi- 
tion to the benefit derived from the fat. 

Mechanical support for the viscera may be ob- 
tained by using abdominal bandage or adhesive 
strips. If the binder be used, it should fit snugly, 
and have straps to prevent "riding the hips. ,, If 



44 DISEASES OF THE INTESTINES. 

adhesive, use six-inch zinc oxid, and cut them long 
enough to extend three-fourths around the body. 
Apply in recumbent posture, beginning in the hypo- 
gastric region. 

Drugs are indicated when tonics are needed. 
Strychnin may then be used to good advantage. 
Operation for replacing organs and suturing them 
is indicated in a few cases with neurasthenia, yet 
not all neurasthenics should be operated upon. 

Caution. When visceroptosis is discovered in a 
patient, it is well not to tell him, as it often forms a 
basis for many imaginary disorders in the neuras- 
thenic or hysterical. 



CHAPTER III. 

DISEASES OF THE LIVER. 

Icterus (Jaundice). 

Remember that icterus, or jaundice, is a symptom, 
and may be found in a variety of conditions. It is 
due to alteration of bile or occlusion of ducts. 

Examine the urine before diagnosing jaundice, al- 
though the tissues be discolored. When the urine 
contains bile pigments, the froth formed by shaking 
it is colored yellow. Nitric acid will give the play 
of colors, best observed on a white porcelain dish. 
Albumin will usually be found in the urine. 

Remember that the pulse and respirations are 
greatly reduced in frequency, especially the respira- 
tory rate. 

Remember that cholemic intoxication may occur, 
manifested by delirium, coma, convulsions, and 
death. 

Remember that hemorrhages are frequent, and no 
operation should be attempted unless absolutely nec- 
essary. 

Intense pruritus and sweating, often localized to 
the palms and abdomen, occur in chronic icterus. 

Grayish-colored stools, with putrid odor, are due 
to the absence of bile in the intestine. 

Always examine the liver and gallbladder care- 
fully in all cases of jaundice. 

45 



46 diseases of the livek. 

Treatment. 

Diet. Avoid fats, alcohol, tea, coffee, and meats. 
An exclusive milk diet is best. Calomel in broken 
doses (gr. % hourly until gr. iij are taken), followed 
in four hours by saline. The bowels may be regu- 
lated by copious enemata; these are supposed to 
stimulate contractions of the gallbladder. Or saline 
aperient waters may be given ; best given on arising 
before food is taken. 

Where gastrointestinal catarrh exists, the follow- 
ing may be used : 

B Acidi hydrochlorici diluti 3 j 

Tincturae nucis vomicae 3 iv 

Tincturee gentianae compositae q. s. ad 3 iv 
Misce. 
Sig. : Teaspoonful after meals. 

Or: 

B Creosoti . . . TTL iv 

Bismuthi subcarbonatis 3 j 

Aquae calcis q. s. ad 3 j 

Misce. 

Sig.: Teaspoonful every half hour. 

Catarrh of bile duct use: 

IJ Sodii salicylates 3 iv 

Ammonii muriatici 3 j 

Aquae menthae piperitae . . . . q. s. ad % vj 
Misce. 
Sig.: Dessertspoonful after meals. 

Or: 

R Fel bovis gr. xxx 

Salolis 3 i j 

Misce et fiant capsulae No. XII. 

Sig.: Capsule three hours after meals. 



ICTERUS PORTAL CIRRHOSIS. 47 



Or: 



IJ Extracti aloes 3 ss 

Sodii bicarbonatis 3 j 

Extracti taraxaci q. s 

Misce et fiant pilulae No. LX. 

Sig. : 2 pills night and morning. ( Catarrhal. ) 

Or: 

Ifc Succi taraxaci 5 i j 

Sodii bicarbonatis 3 vj 

Tincturae rhei 3 vj 

Infusi gentianae q. s. ad § xi j 

Misce et fiat misturas. 

Sig.: Tablespoonful three times daily. (Catarrhal.) 

Urotropin gr. v-gr. vj three times a day should be 
administered for its power over any inflammatory 
condition in the gallbladder. Sodium salicylate in 
5-grain doses every four hours also has a beneficial 
influence on the consistency of the bile. For the 
itching use warm baths, or pilocarpin, given hypo- 
dermatically gr. %2-gr. %, has been highly recom- 
mended. The chilling of the skin must be prevented 
by warm clothing. In chronic cases dilute nitro- 
hydrochloric acid in 20-minim doses in half an ounce 
of the infusion of calumba an hour before meals is 
often used. Silver nitrate gr. % three times daily 
over long period is highly spoken of, but should be 
used cautiously. 

Portal Cirrhosis (Lsennec's Cirrhosis, Alcoholic 
Cirrhosis). 

Remember that it usually occurs past forty years 
of age, and frequently with an alcoholic history. The 



48 DISEASES OF THE LIVER. 

liver is shrunken; hence dullness on percussion is 
diminished, especially over the left lobe. In ad- 
vanced cases nodules may be felt along the borders 
of the liver. 

Remember that jaundice is rare in this form of 
cirrhosis, but obstruction to the portal vein radicles 
causes congestion of gastrointestinal mucosa. 
Hemorrhage is frequent, either from esophageal 
veins, the stomach, the intestines, or hemorrhoids. 
Ascites occurs, and the amount of fluid in the abdo- 
men may be so large as to endanger life unless re- 
lieved. Dropsy of lower extremities (anasarca) oc- 
curs after the ascites, and is caused by the pressure 
of the ascitic fluid upon the large veins. 

Remember that in the nutmeg liver, due to car- 
diac lesion, the anasarca precedes the ascites and is 
due to failing cardiac force. 

Remember that in portal cirrhosis the abdominal 
veins are distended, due to an attempt to establish 
collateral circulation. 

Remember that nutrition suffers, urea excretion 
is less, and albumin is usually found in the urine. 

Always make a pelvic examination in women, so 
as to exclude an ovarian cyst. 

Treatment. 

Alcohol in any form must be absolutely prohibited. 
Do not prescribe tinctures in the treatment. All 
spices and irritants must be excluded. 

The diet must be plain and simple, easy to digest, 



PORTAL CIRRHOSIS. 49 

and nutritious. At the beginning of treatment an 
exclusive milk diet is best. Vegetables may be 
added; always use those containing least amount of 
starch. Later white meats may be allowed. Com- 
plete rest and plenty of fresh air is necessary. 
Bowels should be kept open by salines or calomel. 
Avoid drastic purgatives; rhubarb, senna, cascara, 
or cream of tartar may be used. 

If hematemesis occurs, rest in bed and treatment 
outlined under that head should be followed. 

Remember that diarrhea in these cases is often 
beneficial, and do not be too anxious about checking 
it, for ascites can be relieved by drugs only through 
the kidneys or bowels. 

To increase urination, the following is good: 

IJ Hydrargyri chloridi mitis, 

Pulveris digitalis, 

Pulveris scillae aa gr. vj 

Misce et fiant pilulae No. VI. 
Sig. : Pill three times daily. 

Or: 

Ifc Potassii citratis, 

Potassii acetatis aa, 3 iiss 

Spiritus setheris nitrosi 3 iv 

Liquoris ammonii acetatis g ij 

Tincturse digitalis TTL lxxx 

Syrupi acidi citrici q. s. ad 5 iv 

Misce. 

Sig.: Dessertspoonful four times daily. 

To purge, use: 

B Elaterini gr. j 

Pulveris glycyrrhizse q. s. 

Misce et fiant pilulse No. VIII. 

Sig. : 1 pill every four hours until free catharsis. 



50 DISEASES OF THE LIVER. 

Apocynum cannabinum is an excellent drng. 
Specific tinctnre (Lloyd) is generally used in doses 
of 2 to 3 minims every three hours; often called the 
vegetable trochar. The iodids and ammonium chlo- 
rid are thought by some to be beneficial. 

B Ammonii iodidi 3 j 

Tincturae cardamomi composite . . 3 iv 
Aquae menthae piperita . . . . q. s. ad % ij 

Misce. 

Sig. : Teaspoonful before meals. 

Or: 

B Hydrargyri perchloridi gr. j 

Ammonii chloridi 3 ij 

Syrupi tolutani % j 

Aquae q. s. ad S iij 

Misce. 

Sig.: Teaspoonful three times daily. 

Ascites should be relieved by paracentesis. This 
is by far the safest course, and, with very ordinary 
care and cleanliness, is practically harmless. Don't 
wait for a large accumulation of fluid, so that res- 
piration, digestion, and cardiac contractions are in- 
terfered with. Tonics should be used, and of these 
none are better than the following: 

B Elixiris ferri, quininse et strychninae % ij 
Sig.: Dessertspoonful after meals. 

It should be remembered that each dose contains 
% grain of strychnin. 

Surgery offers no better result than medicine in 
these cases. Collateral circulation will relieve por- 
tal congestion, but throws products directly into the 
systemic circulation that should first be modified 
by specific action of liver. 



BILIARY CIRRHOSIS. 51 

Biliary Cirrhosis. 

Remember that in this form of cirrhosis there is 
no ascites, but chronic jaundice and an enlarged 
spleen. It occurs in early adult life. Heredity is 
a factor, and many cases are on record of families 
developing this condition. In many of the specific 
fevers, as scarlatina and typhoid, it develops. 
Pyogenic cocci have been found in many cases; 
hence it is probably of toxic origin. 

Remember that this occurs between the twentieth 
and thirty-fifth years; there is no alcoholic history. 
Chronic icterus without ascites, with bile pigments 
in the urine. The stools are of normal color, and the 
liver and spleen are enlarged. These are the char- 
acteristics of Hanot's cirrhosis. 

Remember that the onset is announced by fever, 
anorexia, pain and dragging in hepatic region, with 
swelling of liver and spleen. The fever subsides, 
the patient feels well, but the liver and spleen re- 
main large. These acute exacerbations occur peri- 
odically. Hemorrhage is very rare. 

Remember that it is rare to find jaundice in por- 
tal cirrhosis, while ascites is common. 

The presence of gallstone causes attack of colic, 
in which the pain is severe and agonizing, but the 
spleen is not enlarged, the jaundice is deeper, and 
the stools are clay-colored. 

Malignant disease of the liver runs a much shorter 
course; there is great wasting and frequent occur- 
rence of complete obstruction, with jaundice. The 



52 DISEASES OF THE LIVER. 

spleen is not enlarged. Cancer of the liver occurs 
in advanced life. 

Remember that jaundice begins early and gradu- 
ally deepens in contradistinction to portal cirrhosis. 
The liver is also enlarged. 

Treatment. 

Patient should lead a quiet life, with regulated 
exercise. During crisis of the disease he should be 
confined to the bed. Must avoid fatigue and ex- 
posure to cold. 

Diet must be simple, nutritious, and easily di- 
gested. Should contain no stimulating substances. 
During crisis an exclusive milk diet is best. Bowels 
must be kept open, and salines are the best. 
Calomel gr. %o-gr. Vz every three hours for three 
days or longer is highly recommended. Salol gr. v- 
gr. x after meals is indicated in offensive stools. The 
saline mineral waters are allowable. Give glass be- 
fore breakfast and give it hot. 

Abscess of the Liver. 

Remember that some cases can be diagnosed with 
certainty, some probably, and in some the diagnosis 
is impossible. 

Make it a rule, which should never be broken, 
to make a positive diagnosis of liver abscess only 
when a source for the formation of pus has been 
demonstrated or can be surmised with a great de- 
gree of probability. 



ABSCESS OF LIVER. 53 

Always pay special attention to inflammations in 
the region of the portal vein — gastric nicer, appen- 
dicitis, dysentery, pnrulent hemorrhoids. 

Remember that it may follow wounds, especially 
of bones of the head or of body; gallstones, pulmon- 
ary gangrene, endocarditis. 

Remember that the presence of fever narrows the 
diagnosis to hepatic abscess and acute yellow atro- 
phy. Fever is very rare in carcinoma. 

Remember that the liver is usually enlarged, and 
it is most marked in the right lobe; in contradistinc- 
tion to all other enlargements, it is upward. It is 
most pronounced in midaxillary line on percussion, 
and is usually normal at the vertebral column and 
at the midsternal and parasternal lines. "While there 
is some icterus present, marked jaundice is rare. 
There is usually pain, but the intensity varies, and 
the liver is painful on palpation, especially so over 
certain areas, probably corresponding to the abscess 
area or to circumscribed peritonitis caused by the 
abscess. 

Remember that the spleen is never enlarged, ex- 
cept where the abscess is caused by pylephlebitis or 
pyemia. 

Remember that some cases closely resemble ma- 
laria. The fever intermits, and the patient has chills 
and sweats. 

Remember in malaria the presence of the Plas- 
modium in the blood and the enlarged, hard spleen, 
and that quinin properly administered invariably 
effects a cure. 



54 DISEASES OF THE LIVER. 

In right side pleuritic exudate the area of dullness, 
spoken of as characteristic of liver abscess, is absent, 
and a dislocation of the heart to the left is present. 

Remember that the evidence obtained by punctur- 
ing the liver with the needle is conclusive if the 
needle enters the abscess. 

Treatment. 

Pyemic abscess and suppurative pylephlebitis are 
invariably fatal, and surgical intervention is not in- 
dicated. Abscess following dysentery is usually sin- 
gle, and surgery offers the best results — practically 
the only hope. If the abscess ruptures into the pleura 
and the patient cough up pus, an operation is not 
indicated. There is no drug that can stop or modify 
it in any way after the onset. The best treatment is 
preventive. 

Acute Yellow Atrophy. 

Fortunately this fatal ailment is rare. 

Remember that pregnancy is an etiologic factor 
in nearly one-half of the reported cases. 

Remember that it may occur in the course of 
biliary cirrhosis. 

The onset is deceptive, and is usually announced 
by gastroduodenal catarrh, accompanied by slight 
icterus, but soon headache, delirium, trembling of 
the muscles, vomiting, and deepening of the icterus 
sets in. 

Coma may develop early and deepens until death, 
or it may develop later. 



ACUTE YELLOW ATROPHY — CANCER OF LIVER. 55 

Urinalysis shows bile pigments, tube casts, with 
marked reduction of urea excreted. Leucin and 
tyrosin, either one or both, are usually, but not al- 
ways, present. The stools are clay-colored. 

A rapid reduction in the size of the liver, usually 
most pronounced in the left lobe, and, as a rule, the 
afebrile course following the initial elevation of tem- 
perature, confirms the diagnosis. 

Treatment. 

The disease is invariably fatal. Being of a toxic 
nature, the channels of elimination should be stimu- 
lated. Saline solution intravenously and free ca- 
tharsis. Gastric sedatives, as bismuth subnitrate, 
may be used to allay the vomiting. We are power- 
less to check its progress. 

Cancer of the Liver. 

Remember that here, as elsewhere in the body, 
cancer, as a rule, occurs in those past midlife — at 
that period where reconstructive changes fall below 
the call of the tissue cells. 

The secondary cancer is more common than the 
primary, but, unless the seat of the primary cancer 
can be located — as in the uterus, rectum, or breast — 
it is impossible to make a differential diagnosis. 

Remember that cancer may be one large tumor, 
when the liver will be large, but smooth; or it may 
be of the nodular form, when nodules can be felt 
over lower border of the liver, or at times even seen. 



56 DISEASES OF THE LIVER. 

Always look for enlarged lymph glands in the 
axilla, inguinal region, or beneath the skin of the 
abdomen in suspected cases. 

Remember that the liver dullness is increased, but 
that it is downward and toward the umbilicus, while 
the upper border remains normal. 

Palpation shows the consistence of the liver to be 
hard, while protuberances may be felt. Emaciation 
and loss of strength is progressive. 

Remember that the enlargement of the liver is 
progressive, and the lower border may eventually 
reach to the umbilicus. 

Remember that the spleen, as a rule, is not en- 
larged. 

Ascites and icterus are produced by pressure of 
the tumor, and both may be extreme or slight. The 
skin is dry, wrinkled, and has a muddy color. Fever 
may be present, and be of intermittent or remittent 
type. 

Remember that cancer of the liver kills in from 
three to fifteen months. 

Treatment. 

The treatment is palliative. There is no thera- 
peutic measure that offers much hope. Surgeons 
have operated on a few early cases with fair results, 
but this therapeutic measure has not been used often 
enough to form a basis from which to draw conclu- 
sions. 



CHAPTER IV. 

DISEASES OF THE GALLBLADDER. 

Gallstones. 

Remember that stones may remain in the gall- 
bladder indefinitely without causing any symptoms. 
The symptoms are caused by an attempt to force the 
stones through the ducts. 

Remember that bacteria produce gallstones, es- 
pecially the typhoid bacilli, and these germs have 
been found in the gallbladder seven years after an 
attack. 

Remember that catarrhal inflammation of the mu- 
cosa of the bladder or hepatic duct lays the founda- 
tion for gallstones. 

Remember that jaundice will not be a symptom 
if the stone lodges in the cystic duct. A plugging 
of the common duct causes atrophy of the gallblad- 
der — just the opposite of what would be expected. 

Remember that an attack of gallstone colic is 
abrupt in onset, and is announced by a sudden seiz- 
ure of severe, agonizing pain in the right hypochon- 
driac region. It radiates to the right shoulder, arm, 
lower thoracic regions, or it may be referred to the 
epigastric region. Rigors and rise of temperature 
usually follow. Vomiting and profuse sweating oc- 
cur. The vomiting often mitigates the pain, and 
may thus lead to an error in diagnosis. The pulse 

57 



58 DISEASES OP THE GALLBLADDER. 

becomes weak and rapid, and the patient may col- 
lapse. 

Tenderness over the area of the gallbladder is 
found. Friction sound can in many cases be heard; 
in almost all cases the thrill can be felt on palpation. 

Remember that the pain in gastralgia is relieved 
by pressure, and usually terminates suddenly by 
eructations and the voiding of a large quantity of 
urine. 

The pain of peptic ulcer is more constant, and is 
decidedly more directly influenced by taking of food. 
Hematemesis occurs in the course of the disease, but 
jaundice never. 

Treatment. 

Like appendicitis, the treatment naturally divides 
itself into the treatment of acute attack of colic and 
treatment during the interval. 

Gallstone Colic. Two things are necessary — first, 
to relieve the spasmodic contraction of the wall of 
the duct, and, second, to relieve the pain. 

Atropin sulphate gr. %o hypodermatically, to be 
repeated in one hour, is the most powerful means at 
our command to relieve spasmodic contraction. If 
two doses do not affect, it is not wise to adminis- 
ter more atropin because of danger of poisoning the 
patient. Put the patient into a hot- water bath and 
keep him there half an hour. The heat relieves pain 
and assists in relaxing the patient. 

Morphin is indicated if no relief by the above 



GALLSTONES. 59 

treatment is obtained in one or two hours. Give 
gr. %-gr. ss hypodermatically. 

Chloroform inhalations may be used in the place 
of morphin. 

Yeo insists on giving patient a tumblerful of very 
hot water to sip in which is dissolved 1 dram of 
sodium salicylate and 2 scruples of sodium bicar- 
bonate, even though the patient vomits the first few 
mouthfuls swallowed. 

There is no drug that will dissolve the stones. 

Treatment in Interval. 

Olive oil is thought by some to assist in passing 
stones by acting as a solvent. 

B Olei olivse 3 vis 

Spiritus vini gallici 3 v 

Mentholis gr. iij 

Vitelli ovi S j 

Misce et fiat emulsio. 

Sig. : To be taken within one hour, one-half a*t a time. 

Glycerin is used by many. One ounce a day, with 
lemon juice, is given. Other combinations may be 
used, as: 

Ifc Sodii salicylatis 3 iiss 

Aquae menthae piperita 3 iv 

Misce. 

Sig.: Dessertspoonful three or four times a day, prefer- 
ably after meals. 

Or: 

I£ Sodii succinatis 9 iv 

Aquae I] 

Syrupi aurantii q. s. ad % ij 

Misce. 

Sig.: Teaspoonful before eating. 



60 DISEASES OF THE GALLBLADDER. 

Operation should be advised in repeated attacks 
of gallstone colic, a distended gallbladder asso- 
ciated with attacks of pain or with fever, and when 
a stone is permanently lodged in the common duct. 
It is best not to defer operation too long, as chronic 
icterus of long duration greatly increases the dan- 
gers of operation. Probably the time will come 
when the same rule governing operations in appen- 
dicitis will be followed in gallstone affections. 

Suppurative Cholangeitis. 

Remember that gallstones are the most frequent 
cause. However, typhoid, grip, cancer of the bile 
ducts, and hydatid disease may be the cause. 

Remember that the infection may be universal, ex- 
tending to practically all the bile ducts, or it may be 
limited to a few of the larger ones. 

Remember that there is a progressive hepatic en- 
largement, so that the tumor may reach the um- 
bilicus. 

Remember that the enlarged liver is uniform, 
smooth, and tender to pressure. 

Remember that pain is variable, and may be ab- 
sent. It is usually present when due to gallstones, 
and it will then be paroxysmal and severe, and each 
attack of pain may be accompanied by chill and the 
jaundice be intensified. 

Remember that icterus is always present, and is 
persistent and intense. 

Remember that symptoms of an active infection 



SUPPURATIVE CHOLANGEITIS. 61 

are present, such as fever, rigors, and profuse per- 
spiration. There is rapid loss of flesh and strength. 

Remember that the pancreatic ducts are frequent- 
ly involved because of proximity, and there follows 
a pancreatic abscess. 

Remember that the gallbladder is usually dis- 
tended and palpable. The blood count shows leu- 
cocytosis. 

Remember that malaria shows the Plasmodium in 
the blood and the absence of leucocytosis, while in 
suppurative cholangeitis the paroxysms of chill, 
fever, and sweats lack the regular periodicity seen 
in malaria. 

Treatment. 

The treatment is entirely surgical. For the 
proper operation, consult works on surgery. The 
physician should advise operation, providing the 
patient is in a condition to endure it. 



CHAPTEE V. 

DISEASES OF THE PANCREAS AND 
PERITONEUM. 

Hemorrhage. 

This is of great importance from the medico-legal 
point of view. 

Remember that the onset is sudden, and the 
patient may be pursuing his usual occupation when 
he is seized suddenly with a severe epigastric pain, 
which steadily increases in severity. At the onset 
of the pain nausea and vomiting set in. The vomit- 
ing is obstinate, consisting at first of stomach con- 
tents and later is bilious, but never fecal. 

Remember that this condition is nearly always 
mistaken for intestinal obstruction, but the absence 
of fecal vomiting and the appearance of a palpable 
swelling in the epigastric region would exclude ob- 
structions. 

The patient becomes restless, surface cold and 
clammy, with a feeble, rapid, thready pulse. Tem- 
perature is normal or subnormal, and the patient 
loses consciousness, which terminates fatally in 
from twenty-four to forty-eight hours. 

Treatment. 

For loss of the blood use saline solution. Relieve 
pain and distress with morphin and atropin. Use 

62 



HEMORRHAGE ACUTE PANCREATITIS. 63 

strychnin for heart depression, and do a lapar- 
otomy as soon as the patient can be prepared. The 
collapse and great prostration makes it extremely 
hard to get a surgeon to operate. 

Acute Pancreatitis. 

Remember that the onset is sudden in stout adult 
males with an alcoholic or gallstone history. 
Remember that the initial symptoms are: 

1. Epigastric pain, usually severe and agonizing, 
and is diffused over the epigastric region. 

2. Tenderness, usually over the head of the pan- 
creas, but may move to the left over the body or 
tail. The epigastric region is swollen and the recti 
are tense. 

3. Collapse occurs early, and is an important 
sign; often severe, and threatens immediate death. 
The pulse is rapid and there may be cyanosis. 

4. Vomiting is severe and obstinate. Food, mucus, 
and, at times, blood is brought up. 

5. Constipation is present, and thus simulating 
intestinal obstruction, but remember that flatus is 
passed. 

Remember that intestinal obstruction is less 
severe in onset; there is distention of the abdomen, 
which is very rarely confined to epigastric region, 
and the peristaltic waves may be seen above the 
obstruction, while blood and mucus will be found 
in the stool if the obstruction is not complete. 



64 diseases of the pancreas and peritoneum. 

Treatment. 

Use morphin and atropin for the pain. Feed per 
rectum. Use stimulants freely in collapse. Opera- 
tion is indicated if the collapse is not too profound. 

Chronic Pancreatitis. 

Remember that this occurs most frequently in 
the fourth and fifth decades of life, at the time when 
malignancy may be expected. The onset is gradual, 
beginning as gradual emaciation and weakness. 
Anorexia, and in some a loathing of food. 

Remember that the examination of feces reveals 
large amount of pale-colored passages, resembling 
the stools of icterus. Fat and muscle fibers of un- 
digested meat are found. 

Remember that recurrent attacks of epigastric 
pain, with bilious vomiting, may occur. The pain 
is referred to a point a little above the umbilicus, 
but does not radiate. 

Jaundice may occur, but it gradually deepens, 
and the gallbladder is distended. 

Palpation reveals a hard tumor over the head of 
the pancreas, which may be at times mistaken for 
tumor of the gland. 

Remember that in gallstones the onset is abrupt, 
with severe colicky pains, that radiate to the shoul- 
der, and jaundice, when present, is not so deep, 
while the gallbladder shrinks and is not palpable. 

Remember that glycosuria is present only in 
those cases where the islands of Langerhans are in- 



CHRONIC PANCREATITIS — PANCREATIC CYSTS. 65 

volved, but indican in the urine is decreased be- 
cause of the incomplete digestion of the proteids of 
the food. 

Treatment. 

In severe, long-standing cases, only operation 
will give relief. Opening and draining the gall- 
bladder or anastomosis is indicated. Where icterus 
is present, calcium lactate gr. xv-3 j three times a 
day before operation increases the coagulability of 
the blood. Feeding extract of the pancreas is 
thought by some to be helpful in assisting in diges- 
tion of proteids and assimilation of fats. 

Pancreatic Cysts. 

Cysts are most often found between the twentieth 
and fortieth years. 

Remember that most cysts are due either to 
trauma, inflammation, or impacted calculi. 

Remember that palpation is the method of diag- 
nosing cysts, and reveals a deep-seated, retro- 
peritoneal swelling located in the epigastric region, 
usually in the median line or slightly to the left. 
Inflation of the stomach and colon shows the tumor 
lying between them. In form it is round, oval, and 
smooth. 

Remember that the tumor is immobile; has no 
respiratory movements, and very little, if any, on 
palpation. 

Jaundice occurs only when a large cyst presses 
on the duct and is never deep. Vomiting and con- 



66 DISEASES OF THE PANCREAS AND PERITONEUM. 

stipation, when present, is due to the same cause. 
Fluctuation may be obtained in large cysts. 

Remember that fatty stools, containing undi- 
gested muscle fibers, are not found in all cases, but 
are very significant when they occur. Glycosuria 
may be present when large portion of the gland is 
involved. 

Always obtain a complete history in large abdomi- 
nal cysts, and make a thorough physical examina- 
tion with patient in Trendelenburg position in dif- 
ferentiating pancreatic and ovarian cysts. 

Remember that tumor of transverse colon is much 
more superficial in location, and that pancreatic 
cysts have a very remarkable feature of transitory 
disappearance. 

Treatment. 

The treatment is entirely surgical. Opening and 
draining the cyst is much the better, as it gives a 
much lower death rate. 

Carcinoma of the Pancreas. 

When the growth starts in the head of the pan- 
creas, sooner or later the duct is completely ob- 
structed with dilatation and retention cysts in tail 
of the organ. 

Remember that the common duct passes through 
the head of the pancreas or just behind it, and the 
hardened tumor eventually produces obstruction of 
the common duct, causing distention of the gall- 



CARCINOMA OF PANCREAS. 67 

bladder, enlargement of the liver, and a severe, 
progressive, and permanent jaundice. 

Pressure on the portal vein causes ascites, which 
is often pronounced, and often edema of the legs 
is caused by pressure on the cava. 

The bowels are irregular, and the striking fea- 
tures of the feces are their pale, soft, bulky, and 
offensive character and the great excess of fats, due 
to the lack of pancreatic ferments. 

Remember that the rapid emaciation, the loss of 
strength, and anorexia, with dyspeptic symptoms, 
are present. 

Remember that the intense, permanent jaundice, 
with little or no pain, and distended, palpable gall- 
bladder exclude biliary stones. 

Remember that in interstitial pancreatitis the 
history is much longer, emaciation less marked, 
pain and tenderness above the umbilicus more 
common. In many cases a hard, immobile tumor is 
palpable in the epigastrium. 

Treatment. 

Treatment is palliative. While the distended 
gallbladder may be opened and drained, or complete 
extirpation of the gland performed, it is doubtful 
whether permanent recovery follows. Morphin 
should be used if there be pain. Rectal feeding 
should be followed to keep up the strength as long 
as possible. 



68 DISEASES OF THE PANCREAS AND PERITONEUM. 

Acute Peritonitis. 

Remember that Bright 's disease, gout, and arte- 
riosclerosis are often terminated by acute peri- 
tonitis. 

Always get a careful history of previous condi- 
tion, as often a clew may be had of the starting 
point. 

Remember that inflammation of the peritoneum 
is secondary to inflammation of contained viscera 
or trauma. 

Remember that the mental condition of the pa- 
tient will modify the symptoms of onset. 

Remember that shock is a conspicuous symp- 
tom, announcing the onset of peritonitis, and is due 
either to perforation or it may occur later from 
toxemia. 

Remember that the chief features of the clinical 
picture are pain, tenderness, rigidity, vomiting, 
pulse, attitude, and facies. 

Remember that, while the pain is usually greatest 
near the navel, yet the primary lesion may alter it 
some — as in gastric perforation the pain may be 
epigastric and in the back. 

Remember that the important thing about the ten- 
derness is that it is deep and not superficial. The 
muscular rigidity is the same as found over an 
inflamed appendix, except it is found over all the 
abdominal muscles. 

Remember that the pulse is rapid, small, and 
hard — the wiry pulse — occurring more often in this 



ACUTE PERITONITIS. 69 

than any other affection. The patient lies on his 
back, with limbs drawn np and shoulders elevated. 

Early, the abdomen may be retracted — the 
scaphoid — bnt later is distended and tympanitic. 

Remember that the facies, Hippocrates' descrip- 
tion, can not be improved — "a sharp nose, hollow 
eyes, collapsed temples; the ears cold, contracted, 
and their lobes turned out; the skin about the fore- 
head rough, distended, and parched; the color of 
the whole face being brown, black, livid, or lead- 
colored.' ' Vomiting occurs early, and soon be- 
comes bilious or even fecal. 

Respirations are shallow and of costal type. The 
diaphragm is high, liver and splenic dullness dis- 
appears, and the apex beat of heart pushed up into 
fourth costal space. 

Remember that hysterical patients have so simu- 
lated peritonitis as to deceive the very elect. 

Remember that in enterocolitis the pain is 
colicky; there is diarrhea and tenesmus; there is 
collapse, but it is due to rapid loss of water and 
toxemia. 

Remember that in intestinal obstruction there is 
complete, sudden stoppage of the bowels — no flatus 
passing; or there are bloody stools (depending on 
the cause) ; an immovable, tense mass at the point 
of obstruction, which may be seen or felt. 

Remember that tuberculosis must not be forgotten 
as a causative factor, and that usually symptoms of 
tuberculosis are found. 



70 diseases of the pancreas and peritoneum. 

Treatment. 

Only surgical treatment is of any value. Open the 
abdomen; repair the cause if possible; drain; put the 
patient in Fowler's semi-erect posture, with the con- 
tinuous flow into the rectum of hot saline solution 
(page 29). This procedure is now saving three- 
fourths of these patients, which was formerly the 
death rate. 

Diet. Allow nothing by the mouth. Add pano- 
pepton to the salt solution used in the continuous 
flow. 

Never be guilty of willingly treating acute peri- 
tonitis medicinally. There is no valid reason for 
doing so, and the mortality is very high. Opium, 
or any of its derivatives, gives only a false sense 
of relief, and the saline treatment is no better. 



CHAPTER VI. 

DISEASES OF THE KIDNEYS AND BLADDER. 

Movable Kidney. 

Remember that this is decidedly more common in 
women and frequent in hysterical patients. 

Remember that the difference between a palpable, 
movable, and floating kidney is one of degree. 

Remember that palpation is the only way a 
diagnosis can be made. Use the following pro- 
cedure : 

Put the patient in the dorsal position, with the 
head moderately low and the abdominal muscles 
relaxed. Place the left hand in the lumbar region 
behind the eleventh and twelfth ribs. Put the right 
hand in the hypochondriac region in the nipple line, 
just under the edge of the liver. Gently press the 
two hands together, when a firm, round body may 
be detected just below the ribs — this is a palpable 
kidney. 

Have the patient take a deep breath, when the 
fingers may be slipped up over the kidney, but the 
organ can not be pushed below the level of the 
navel — a movable kidney. 

The kidney may be grasped with the hand and 
moved to any part of the abdomen, or even into the 
pelvis — a floating kidney. 

Remember that in a large majority of cases there 

71 



72 DISEASES OF THE KIDNEYS AND BLADDER. 

are no symptoms, and the condition is detected acci- 
dentally, but it is well not to inform the patient. 

Remember that dyspeptic symptoms in a neurotic 
woman that do not yield to ordinary treatment are 
probably due to a displaced kidney. 

Jaundice, slight and of short duration, but recur- 
ring frequently, is probably due to nephroptosis. 
In a floating kidney the kinking of the vessels by a 
twisting of the kidney causes abdominal pain, 
chills, nausea, vomiting, fever, and collapse. The 
amount of urine may be decreased, dark, and contain 
albumin, pus, and blood, and the kidney may be 
tender and swollen. The skin is moist and cold; 
at the close of the attack there may be a copious 
amount of pale urine. Acute hydronephrosis results 
from strangulation of the ureter. Worry and anx- 
iety may cause a loss in weight. 

Treatment. 

The patient should be confined to bed and forced 
feeding resorted to. The object of this is twofold — 
first, it is the best method of treatment for the 
neuroses coexisting, and, second, by putting on fat 
the patient furnishes additional support for the dis- 
placed kidney. The kidney should be held in its 
normal place by a well-fitting bandage applied to 
the abdomen, with or without a pad over the dis- 
placed kidney. 

The following advice from Dr. Potter should be 
heeded: "A properly-fitting bandage is not easy 



MOVABLE KIDNEY — ACUTE NEPHRITIS. 73 

to secure, especially for very thin patients. I rarely 
nse a pad, but attempt to secure the retention of the 
kidney by a well-fitting, long, low corset, or, in more 
difficult cases, by an elastic bandage encircling and 
sustaining the lower two-thirds of the abdomen. 
The physician must carefully examine such contri- 
vances after being applied and worn by the patient. 
No case should be operated upon, in my judgment, 
until every possible medical measure has been thor- 
oughly tried." 

The only medicine indicated is a tonic when the 
appetite fails. 

Acute Nephritis. 

Remember that this condition may complicate any 
of the infectious diseases, and frequently follows 
typhoid and scarlatina. 

Always inquire about medicinal substances used, 
as often the use of potassium chlorate tablets, fre- 
quently used for sore throats, or turpentine, will 
cause acute nephritis. 

Remember that there are two classes of cases — 
one class where the dropsy is extreme, as seen in 
scarlatinal form, while in the other class there is 
little or no dropsy. 

Remember that acute Bright 's disease may exist, 
the anasarca be extreme, but the urine contain no 
albumin, or only a trace. 

Remember uremia may be the first symptom, but 
it usually occurs later. 



74 DISEASES OF THE KIDNEYS AND BLADDER. 

Always examine the urine. It will be dark and of 
a smoky color; high specific gravity; small in 
amount, and contain albumin, tube casts, and often 
blood cells. 

Remember that pleural effusions may be large and 
the lungs edematous, although dropsy is not exten- 
sive. 

Remember that anemia is a prominent and early 
sign, and gives a peculiar, pale complexion. 

Remember that every urine containing abumin is 
not a case of acute nephritis. 

A peculiarity of the dropsy in acute nephritis is 
its irregularity of distribution, and does not always 
gravitate according to the posture of the patient. 

Always examine frequently the urine in preg- 
nancy, especially' in cases complaining of occipital 
headache, or swelling of the ankles, or edema of 
face. 

Remember that it is in syphilitic nephritis that 
large quantities of albumin is found. 

Treatment. 

Often it is easy to discover the etiologic factor, 
which should then be treated rather than the nephri- 
tis. In cases due to malaria, quinin is indicated, 
while in that form occurring in the secondary stage 
of syphilis, mercury will cause a complete and per- 
manent subsidence. The iodids are not so bene- 
ficial as they are in the tertiary stage. In typhoid 
with nephritis, cold baths should not be given on 



ACUTE NEPHRITIS. 75 

account of the sudden cooling of the skin, but tepid 
sponging may be substituted. Care as to medica- 
ments used must be observed, regardless of the 
cause, in many cases. Drugs causing renal irrita- 
tion must be abandoned. Some of these are tar, 
styrax, naphthalin, phenol, oil of turpentine, potas- 
sic chlorate, and cantharides. 

While salicylic acid and its derivatives cause 
renal irritation, they should be used in the treatment 
of a causative articular rheumatism. 

Symptomatic Treatment. The patient should be 
in bed and kept there until all traces of the disease 
have disappeared. Counterirritation over lumbar 
area will relieve renal congestion. Cantharides or 
mustard plaster should not be used because of renal 
irritation. Cupping, wet or dry, leeches, or the appli- 
cation of the actual cautery applied to Petit 's tri- 
angle, as the network of veins here communicate di- 
rect with the perirenal veins, should be followed. In 
severe cases of renal congestion, where there is 
marked diminution of urine, many blood cells, and 
severe lumbar pain, headache, and vomiting, the ap- 
plication of leeches every other day and on alternate 
days, dry cupping morning and night, until the 
severe symptoms have subsided, afford relief. The 
quickest and probably the best way of relieving the 
congestion is by venesection performed on the lower 
extremity. The vena pediaea may be opened and 
10 ounces of blood withdrawn. 

Diet is of supreme importance. All meats and 



76 DISEASES OF THE KIDNEYS AND BLADDER. 

preparations made from meat must be excluded. 
Strictly milk diet is best. Buttermilk, gruels made 
of arrow-root, oatmeal, barley-water, butter, crack- 
ers, and cream may be allowed. All condiments 
and alcohol should be forbidden. The diet should 
be salt (sodium chlorid), free, especially if there 
be much dropsy. 

Cases due to bacterial toxin should be given plenty 
of water to dilute the poison and reduce the renal 
irritation. 

Diuretics. Alkaline mineral waters should be 
used freely. When they fail to increase urinary se- 
cretion, some of the following may be used to ad- 
vantage : 

Caffein is excellent because it is cardiac as well 
as kidney stimulant. Never give over 10 grains 
daily, as 15 grains will cause albuminuria. 

R Caffein, 

Sodii benzoatis aa, gr. ii j 

Misce et fiat capsula No. I. Dentur tales capsular No. XV. 
Sig. : Capsule three times a day. 

The best form is probably the double salt: 

R- Caffein-sodii salicylatis gr. ii j 

Sig.: One such dose three times a day. 

Potassium acetate in large doses is also a good 
diuretic : 

TJ Potassii acetatis 3 iv-3 v 

Syrupi rubi idaei 3 ss 

Aquae destillata^ q. s. ad 5 vj 

Misce. 

Tablespoonful every two hours. 



ACUTE NEPHRITIS. 77 

In the early stage the following is a good diu- 
retic and also equalizes the circulation: 

Ifc Tincturae aconiti Til xij 

Spiritus aetheris nitrosi 3 vj 

Solutio potassii citratis 3 ij 

Syrupi tolutani q. s. ad % iij 

Misce et fiat solutio. 

Sig. : Teaspoonful every two hours. 

Or: 

Ifc Potassii citratis 5 ss 

Infusi digitalis 5 j 

Aquae 5 j 

Misce. 

Sig.: Dessertspoonful every three hours. 

Where the heart needs stimulating, the following 
is excellent: 

B Tincturae digitalis 3 v 

Vini scillae 3 iss 

Spiritus aetheris nitrosi 5 ij 

Misce. 

Sig. : Teaspoonful every three or four hours. 

Diaphoretics. To increase the activity of the skin 
is to lessen the tension on the kidney. Hot baths, 
and have the patient sleep between blankets dressed 
in light flannel gown. Pilocarpin can be used with 
safety only in a selected number of cases. It should 
never be given to children. It is best administered 
hypodermatically. It is better always to give 
minimum dose — say, gr. M.5 — and repeat in one hour, 
than to give one dose of gr. %. 

Purging should be moderate, but is of great bene- 
fit. A good rule is, "purge one day and sweat the 
next. ' ■ 



78 DISEASES OF THE KIDNEYS AND BLADDER. 

A very excellent cathartic is the following: 

B Pulveris jalapse composite, 

Potassii bitartratis aa 3 ss-3 j 

Misce et fiat pulvere No. I. Dentur tales No. X. 
Sig. : 1 powder every other morning. 

Chronic Parenchymatous Nephritis. 

Remember that the urine for the twenty-four 
hours is diminished in quantity, has a dark, smoky 
color, and is turbid from the presence of urates. 
The specific gravity is high, and on standing a 
heavy sediment is deposited. Albumin is always 
present, and is more abundant in day than night 
urine. The total amount of solids — as urea, phos- 
phates, and chlorids — is reduced. Hyaline, granu- 
lar, fatty, and epithelial casts are abundant. 

Remember that edema is frequent and often the 
first symptom to attract attention. Occurs first 
about the eyes, and seen only in the morning, but 
later it is permanent and becomes general. The 
patient 's appearance is very suggestive — puffy eyes, 
pale and swollen cheeks, dull expression, distended 
abdomen, and shapeless wrists and ankles. 

Remember that anemia is a prominent and pro- 
nounced symptom in this form of nephritis. The 
pulse small, soft, and rapid. The apex beat weak, 
indicating dilatation. 

Remember that the first manifestation of long ex- 
isting trouble may be epileptiform seizures, or an 
attack of uremic dyspnea simulating asthma. 

Remember that a general failure of health, 



CHRONIC PARENCHYMATOUS NEPHRITIS. 79 

shown by loss of energy, easily fatigued, loss of 
appetite with digestive disturbances, is frequently 
found early in this condition. 

Remember that vomiting occurs often in the 
course of renal trouble, and usually caused at sight 
of or on taking food. The nausea accompanying 
the vomiting is intense. 

Remember the examination of the eyes, as 
albuminuria retinitis is one of the most character- 
istic features of this form of renal trouble. 

Remember that in many asthmatic seizures the 
trouble is caused by a lesion of the kidney, and the 
albuminuria is causative and not dependent upon 
the asthma. 

Treatment. 

Rest in bed is best. This should be continued for 
as long a period of time as possible, as it reduces 
albuminuria and reduces waste products thrown 
upon the kidneys for excretion. The patient should 
be dressed in canton flannel, and lie between blank- 
ets, so that the skin may be kept active. 

Diet. Nothing should be allowed that increases 
the work of the kidneys. Milk diet is excellent, but 
it is impossible to administer enough to keep up 
the body nutrition. Two to three pints of milk dur- 
ing the day, to which cream has been added, is suf- 
ficient. Calcium carbonate gr. v-gr. x, administered 
with the milk, precipitates the phosphates and thus 
prevents their being absorbed and irritating the 



80 DISEASES OF THE KIDNEYS AND BLADDER. 

kidneys. Meat, as veal, mutton (well cooked), and 
beef, may be allowed restricted. Carbohydrates and 
sugar must furnish the bulk of nutrition. Potatoes, 
rice, butter, sugar, eggs (cooked), olive oil, and cod- 
liver oil are all excellent in varying the diet. A 
moderate amount of all fresh fruits, except cran- 
berries, is allowable. Onions, garlic, tomatoes, rad- 
ishes, asparagus, and celery must be forbidden, 
while beans, peas, turnips, carrots, lettuce, and 
cauliflower should be given. 

Salt. Most nephritics eliminate sodium chloride 
imperfectly, so that much of it is retained. Sodium 
chloride controls osmosis in the economy. When 
retained in the blood, it becomes hypertonic and 
less water is excreted by the skin, lungs, and kid- 
neys. Dropsy then begins or increases, as does 
albuminuria; hence a diet free, or as near that as 
possible, will lessen both hydrops and the albumin. 

Water. Care must be exercised in the amount of 
water taken. An excessive quantity, thus engorg- 
ing the blood and lymph, and increasing the work 
of the heart, is just as harmful as too little given. 
About three pints are an average amount to be given 
in twenty-four hours. 

Baths. Lukewarm or hot baths three or four 
times a week, followed by a light sweat, are advis- 
able to keep up the activity of the skin. Where 
atheroma exists, care should be taken. 

Clothing. The feet must be well protected, and 
patient should wear woolen underwear. A flannel 
band over the loins, in addition, is often beneficial. 



CHRONIC INTERSTITIAL NEPHRITIS. 81 

The Bowels. These must be kept open. If con- 
stipated, saline cathartics should be used. The 
compound jalap powder and Eochelle or Epsom 
salts are probably best. The anemia is to be com- 
bated by using iron. The syrup of the iodid of 
iron or the tincture of the chlorid is best; best 
given half an hour after meals. 

Diuretics. Most of them should not be used. 
Cream of tartar 5 j as a refrigerant drink or potas- 
sium citrate gr. xx-gr. xxv are the only safe ones. 
Liquoris f erri et ammonii acetatis 3 j-3 ij (Bash- 
am^ mixture) may be given for its tonic as well as 
diuretic effect. 

Chronic Interstitial Nephritis. 

Remember that this is the lesion occurring in the 
aged and is intimately connected with arterio- 
sclerosis. 

Remember that the urine is greatly increased in 
quantity and is voided so often, especially at night, 
that the patient usually seeks relief of so trouble- 
some a symptom. 

Always examine such cases for enlarged prostate. 

Remember that there are three cardinal findings 
in this condition — cardiovascular, urinary, and 
retinal — and he who invariably examines the urine 
and heart in every instance rarely fails in his 
diagnosis. 

Remember that the increased urine is pale in 
color and low in specific gravity, there is a reduction 



82 DISEASES OF THE KIDNEYS AND BLADDER. 

of solids, and albumin is found only in trace and 
may be absent at times. 

Remember that persistent low specific gravity is 
one of the constant and important features of this 
condition; therefore frequent urinary examinations 
should be made. 

Remember that the hypertrophy of the heart 
causes a displacement of the apex beat downward 
and to the left, and the impulse is forcible and may 
be heaving. 

Remember that the pulse is not only hard, but the 
tension is increased, so that it requires considerable 
pressure to overcome it, and when abolished the 
vessel below can be rolled under the finger. 

Remember that chronic bronchitis, especially in 
the winter, is common. 

Remember that trouble in vision may be the first 
symptom, and caused most frequently by retinal 
hemorrhage. 

Remember that edema is not common, and when 
it appears it is due to cardiac failure. 

Treatment. 

Don't advise the use of large amount of liquids, 
and it is better to restrict them to two pints per 
day. Milk diet is indicated only when uremia 
threatens. 

Remember that in this form of nephritis it is 
more important to watch the heart than the kidneys. 

Diuretics should not be used unless there is a 



CHRONIC INTERSTITIAL NEPHRITIS. 83 

great diminution of quantity of urine or dropsy de- 
velops, and then only for a short period of time. 
At first indication of weakening of heart, adminis- 
ter digitalis, cafrein, camphor, or squills until there 
is cardiac improvement. Drugs should be carefully 
watched for cumulative action because of slow 
excretion. 

Iodids are excellent in many cases, and are espe- 
cially indicated in syphilitic nephritis. Some of 
the cases of syphilitic origin improve under mer- 
cury, while others are made worse, but all respond 
to iodin treatment. 

The dress should be flannel, and patient must be 
careful about catching cold. 

Iron is indicated if anemia is present — shown by 
marked weakness and pallor. 

Bowels should be kept open by use of salines, or, 
perhaps better, by alkaline mineral waters. Calomel 
purge occasionally is very beneficial. 

Skin should be kept active, and this is best done 
by warm baths. 

"When the arterial tension is high, it should be re- 
lieved because of the danger of hemorrhage. This 
is best done with nitroglycerin carefully adminis- 
tered. Begin by giving 1 minim of a 1-percent 
solution (gr. M.90) three times daily and gradually 
increase. On the other hand, where the tension is 
low, as manifested by decreased amount of urine and 
appearance of dropsy, give strychnin or digitalis. 
The latter is best given as an infusion. 



84 DISEASES OF THE KIDNEYS AND BLADDEK. 

Worry and anxiety must be forbidden, and patient 
live a quiet life. 

Uremia. 

Remember that uremia may exist in a latent form. 
The mind is clear and pupils are contracted, muscu- 
lar twitchings and vomiting occur, and the tempera- 
ture is subnormal. 

Remember that coma always accompanies convul- 
sions, but it may develop gradually without convul- 
sions. 

Remember that all cases of intractable headache, 
either occipital or low down in back of the neck, 
call for urinalysis, that threatened uremia may not 
be overlooked. 

Remember that muscular cramp, particularly at 
night in the calves, twitching, monoplegia or hemi- 
plegia, or tingling sensations in the limbs, call for 
urinalysis and the elimination of Bright 's disease. 

Remember that uremic dyspnea may be continu- 
ous or paroxysmal, and at times Cheyne-Stokes 
breathing may be observed. The dyspnea is usually 
nocturnal, and it is very difficult to differentiate 
from true asthenia without the precaution of urin- 
ary examination. 

Remember that cerebral hemorrhage, meningitis, 
and brain tumors must be excluded in the diagnosis. 
The hemiplegia is complete and permanent; vomit- 
ing, tense pulse, and conjugational deviation of the 
eyes are present. 



UREMIA. 85 

In brain tumor may have convulsions, vomiting, 
headache, vertigo, with hemiplegia or monoplegia, 
but in uremia these are transitory, while in tumor 
they are chronic and progressive. 

In meningitis, when headache and vomiting are 
followed by coma without localizing phenomena, 
and the urine contains albumin, spinal puncture and 
examination of some of the spinal fluid is the only 
means of differentiating from uremia. 

Remember that uremia may last for several weeks, 
and patient lie in stupor, with heavily coated, dry 
tongue, rapid and feeble pulse, and muscular 
twitchings, suggesting typhoid or miliary tubercu- 
losis. 

In miliary tuberculosis the pulmonary signs, with 
those of associated pleurisy and pericarditis, will 
differentiate, while Widal reaction of blood, rose 
spots, enlarged and soft spleen, and peculiar tem- 
perature range will assist in correct interpretation 
of the typhoid condition. 

Remember that in opium poisoning the pupils are 
contracted equally, while in uremia they are not 
constant. Examine the eyes for albuminuric retin- 
itis, and urinalysis should be made. The pulse is 
slow, and respiration and the stupor are profound. 
In coma from alcohol the unconsciousness is not 
so profound, and heavy pressure on the supraorbital 
nerve at junction of inner and middle third of orbit 
at the supraorbital notch will always cause a re- 
sponse. The temperature is subnormal and the 



86 DISEASES OF THE KIDNEYS AND BLADDER. 

pupils usually dilated. Place no value upon the 
odor of the breath unless you know the history. 

Remember that uremia occurs most frequently in 
chronic interstitial nephritis, and that the concomi- 
tant vascular changes will be of aid in diagnosis. 

Treatment. 

In an acute attack of uremia there is nothing com- 
parable to venesection — withdrawing half a pint 
of blood and replacing the amount by the saline 
solution by hypodermoclysis. Never used too early, 
but often too late. 

Diaphoretics. Pilocarpin hydrochlorate gr. %- 
gr. % may be given hypodermatically. If heart is 
weak, give cardiac stimulant. May be used with hot 
pack. 

Catharsis. 

B Elaterini gr. % 

Sacchari lactis gr. xv 

Misce et fiant pulveres No. V. 

Sig. : Powder every three hours until free catharsis, then 
daily. 

Or: 

B Hydrargyri chloridi mitis gr. viij 

Pulveris jalapae compositse 9 iv 

Misce et fiant pulveres No. IV. 
Sig.: Powder hourly. 

In case of severe vomiting, elaterina hypodermat- 
ically gr. %o-gr. M.o may be given. 

Cardiac Tonics. With decreased blood pressure 
and small, thready or irregular pulse, heart stimu- 



UEEMIA. 87 

lants to raise pressure within the kidneys is ad- 
visable. Digitalis is excellent, but its action is de- 
layed, so that in acute cases it must be reinforced by 
quicker-acting stimulants. Camphor is best, and 
should be given in large doses — o ij-5 iij of a 10-per- 
cent solution in olive oil hypodermatically during 
the twenty-four hours should be given with the digi- 
talis. 

Convulsions may be treated with hypodermic of 
morphin or inhalations of chloroform. Venesection 
is often very beneficial in this condition, or: 

Ifc Chloralis hydrastis 3 ss 

Potassii bromidi 3 j 

Tincturae veratri veridi TTL xxx 

Syrupi aurantii florum 3 iv 

Aquae q. s. ad 3 i j 

Misce. 

Sig. : Tablespoonful every hour or two as required. 

Or: 

B Pilocarpine hydrochloridi gr. j 

Tincturae veratri veridi TTL xxx 

Syrupi tolutani 3 iv 

Aquae anisi q. s. ad 3 j 

Misce. 

Sig.: Teaspoonful in water, repeated in two or three 
hours, as required. 

Vomiting. This is frequently persistent and ob- 
stinate. The following formulae will indicate the 
best line of treatment: 

B Cerrii oxalitis gr. xv 

Sacchari lactis 3 ss 

Misce et divide in pulveres No. VI. 
Sig.: Powder every three or four hours. 



88 DISEASES OF THE KIDNEYS AND BLADDEE. 

Or: 

B Hydrargyri cliloridi mitis gr. j-gr. iij 

Cerrii oxalitis gr. xx 

Saccliari lactis . . gr. xxx 

Misce et divide in pulveres No. X. 

Sig. : Powder every hour on tongue. 

Ingluvin gr. v, administered every two hours, is 
often good. 

B Creosoti gtt. x 

Emulsio amygdalse 3 iss 

Syrapi simplicis 3 iv 

Misce et fiat emu'sio. 

Sig. : Dessertspoonful every four hours. 

Lavage of the stomach with water at 105° is ex- 
cellent and should be tried early. 

Diarrhea. Don't be too anxious to check it. This 
is one of nature 's methods of ridding the economy of 
toxic material. 

Uremic Asthma. Spirits of ether gtt. x-gtt. xxx 
on sugar several times a day. Or: 

R. Extracti Valerianae gr. v-gr. x 

Dentur tales doses No. XXX. Inclosed in capsule. 
Sig.: Capsule four or five times daily. 

Diet. In an acute attack, starvation or Renon's 
water diet, one quart to three pints daily, with or 
without lactose, for two or three days, gives best 
result. 

In subacute form a diet similar to that of Bright 's 
disease is best. In chronic form the diet varies and 
depends upon the urinary findings. 

Dilute hydrochloric acid, giving from one to three 



UREMIA PYELITIS. 89 

teaspoonfuls in the twenty-four hours, is excellent, 
and probably is indicated, as many cases show hypo- 
acidity. To be given following meals. 

Pyelitis. 

Remember that the great danger in cystitis is 
pyelitis by extension along the ureters. 

Remember that pain in the back or tenderness on 
deep pressure over the affected kidney, with pus in 
the urine and fever of the septic type, are indicative 
of pyelitis. The pyuria may be intermittent, due to 
the plugging of the ureter of the affected side. 
When this occurs, the intermittency excludes cys- 
titis. Coincident with the retention, often a tumor 
mass may be felt on the affected side. 

Remember that the reaction of the urine is usually 
acid, unless cystitis coexists. 

Remember that in cystitis the pain is over the 
bladder and is made worse in the erect posture. 

Remember that painful, frequent micturition and 
an alkaline urine suggest cystitis. 

Remember that in chronic cases of pyelitis, poly- 
uria and a low specific gravity are usual. 

Remember that an infection may extend to the 
ureter from the bladder. 

Treatment. 

Diet. In the acute cases it should be exclusively 
milk. The chronic cases should have diet used in 
nephritis. 



90 DISEASES OF THE KIDXEYS AXD BLADDER. 

Baths. A warm bath should be given two or three 
times a week, and the patient should be carefully 
guarded against catching cold. 

Congestion is best relieved by applying leeches 
over Petit 's triangle, as the veins of this region 
communicate with those of the renal capsule. Free 
catharsis should be employed, both for the conges- 
tion and ridding the body of toxins. The vegetable 
cathartics are best. 

Pain may be relieved by hot applications over the 
affected kidney, or, if severe, by atropin and mor- 
phin. 

Antiseptics are indicated to combat the infection. 
Urotropin is best, but benzoic acid or the sodic salt 
may be used. The action of urotropin is enhanced 
when it is combined with salol. 

B Urotropini, 

Salolis aa9 iiiss 

Misce. Dentur tales doses No. XXV. Inclosed in capsule. 
Sig. : Capsule every three or four hours. 

A capsule containing gr. iss-gr. iij of methylene 
blue may be given three times daily. Gastric dis- 
turbances must be watched for. 

B Acidi benzoici gr. ij-gr. v 

Fiat tabella Xo. I. Dentur tales doses Xo. XX. 
Sig. : Tablet every two hours. 

Or: 

B Sodii benzoatis 3 j 

Extracti gentianae q. s. 

Misce et fiant pilulae Xo. XXX. 
Sig. : 2 pills every two hours. 



PYELITIS HYDRONEPHROSIS. 91 

Or: 

B Sodii benzoatis 3 j 

Syrupi rubi idaei, 

Aquae menthae piperitae aa 3 v j 

Misce. 

Sig. : Tablespoonful two hours after meals. 

Astringents. Lime water, 2 to 3-ounce doses three 
or four times a day, diluted with an equal quantity 
of milk, is excellent. 

B Plumbi acetatiSj 

Pulveris opii aa gr. xxx 

Extracti glycyrrhizae q. s. 

Misce et fiant pilulae No. XXX. 

Sig.: 1 or 2 pills three or four times daily. 

Hydronephrosis. 

Remember that this may be congenital, and either 
unilateral or bilateral. If bilateral, death results in 
a short time. 

Remember that in many cases the obstruction is 
intermittent, and when the obstruction is relieved 
there will be a large quantity of urine with the dis- 
appearance of the renal tumor. 

Remember that when the tumor is of moderate 
size it may be palpated in the renal region, but 
those of extreme size may be mistaken for ascites or 
ovarian cysts. 

Aspiration furnishes conclusive evidence. The 
fluid aspirated will be clear, of low specific gravity, 
with urea and urinary salts. 

Remember that in the history the location of the 
tumor in the beginning is important, as ovarian 



92 DISEASES OF THE KIDNEYS AND BLADDER. 

tumors originate in the pelvis. Ovarian tumors are 
vable, while hydronephrotic tumors are not, un- 
less they occur in a movable kidney. 

Treatment. 

Cases of intermittent hydronephrosis causing no 
serious symptoms should be let alone. "When the 
tumor becomes large, aspiration should be done; the 
needle passed through the flank half way between 
the crest of the ilium and the last rib. "When the 
tumor recurs, it may be incised and drained. Ee- 
moval of the kidney should be done only as a last 
resort. Sometimes the wearing of a pad and band- 
age following aspiration will prevent refilling. 

Nephrolithiasis. 

Depending upon the size of the concretion, we 
have sand, gravel, or stone. 

Remember that all stones are due to a deposit 
upon a framework consisting of albuminous sub- 
stance and at times epithelial cells. 

Pain. Renal stones cause pain. The character 
of the pain depends upon the location of the stone. 
Pain, dull in character, is felt in the loin, frequently 
associated with local tenderness, with the stone in 
the renal pelvis. Certain movements which shake 
the body make it worse. 

Remember that this dull pain and localized ten- 
derness may be found without any urinary changes. 

Remember that renal colic is caused by passing of 



NEPHROLITHIASIS. 93 

stone into the ureter. Pain of renal colic is sharp 
and lancinating, radiating from the renal region 
along the ureter to the bladder, testis, labia, or 
urethra. The testicle is retracted. The kidney is 
sensitive ; there is a continuous desire to urinate, but 
can pass only a few drops of a concentrated, bloody 
urine full of sediment. The general symptoms are 
nausea, vomiting, cold perspiration, chills, weak 
pulse; the dorsal posture is assumed, legs drawn up, 
and the abdominal wall rigid. The pain is greatest 
as the stone passes into the bladder, as the caliber 
of the ureter is smaller at this point. The attack 
ceases abruptly on the passing of the stone from the 
ureter, either into the bladder or back into the renal 
pelvis. After the passage of the stone a profuse 
discharge of urine follows. 

Remember that the absence of hematuria after a 
renal colic speaks strongly against a diagnosis of 
renal calculi. 

Remember in vesical calculi the pain is concen- 
trated over the bladder, and when it radiates to the 
flanks it is felt on both sides. The sudden stoppage 
of the flow in micturition and the positive informa- 
tion obtained by examining the bladder with a stone 
searcher will assist in differentiating. The x-ray in 
competent hands is of great assistance, but is not 
to be absolutely relied upon. While negative find- 
ing does not absolutely exclude stone, the per- 
centage of errors is small. 



94 diseases of the kidneys and bladder. 

Treatment. 

Renal Colic. Prompt immersion in hot bath, 110° 
to 115°, for half an hour often affords relief, but, if 
it does not, give while in the bath hypodermic of 
morphin sulphate gr. %-gr. % with atropin sulphate 
gr. %50-gr. %o, and, if it fails to relieve the pain, 
repeat the morphin in one hour; no relief following 
this, give inhalations of chloroform to slight anes- 
thesia. It is essential, to further treatment, that 
careful watch be kept to detect sand or gravel in 
the urine, so that the kind of stone may be deter- 
mined — whether uratic, oxalate, or phosphatic. In 
uratic or oxalate stones the acidity of the urine 
must be reduced. For this purpose alkalies are 
given. 

The following effervescent powder is good: 

3 Lithii carbonatis gr. iv 

Sodii bicarbonatis gr. v 

Misce et fiat pulvere No. I. 
No. 1. 

B Acidi citrici gr. viij 

No. 2. 

Dentur tales doses Nos. 1 and 2 No. X. 
Sig. : 1 of each powder in half a glass of water three 
times daily; drink while effervescing. 

Glycerin in large doses is highly recommended 
in assisting in passage of the stone. 

B Glycerini, 

Succi limonis aa § j 

Misce. 

Sig. : 4 tablespoonfuls daily. 

Or put 1 ounce of glycerin into 1 quart of lemon- 
ade and give during the day. 



NEPHROLITHIASIS. 95 

IJ Potassii acetatis 3 iij 

Aquae cinnamomi q. s. ad § ij 

Misce. 

Sig. : Teaspoonful every two or three hours until urine 
is only slightly acid. 

Or: 

IJ Lithii citratis gr. xx 

Sodii citratis 3 i j 

Aquae q. s. ad § i j 

Misce. 

Sig.: Teaspoonful in carbonated water every two or 
three hours until urine is only slightly acid. 

Or: 

IJ Sodii benzoatis 3 isa 

Syrupi tolutani 3 v 

Aquse destillatse q. s. ad 3 vj 

Misce. 

Sig.: Tablespoonful every two hours. 

As a preventive of urate deposit the following 
may be used: 

IJ Magnesii carbonatis 3 j 

Acidi citrici 3 ij 

Sodii biboratis 3 ij 

Aquae q. a. ad % viij 

Misce. 

Sig.: Teaspoonful three times daily. 

Calcium carbonate influences the monosodium 
and disodium phosphates in such a way that the 
urine can hold a greater quantity of uric acid in 
solution without losing its acid reaction. 

IJ Calcii carbonatis gr. x 

Lithii carbonatis gr. j-gr. i j 

Misce et fiat pulvere No. I. Dentur tales doses No. XX. 
Sig.: Powder every three hours with glass of water until 
urine only slightly acid; then three or four times a day. 



96 DISEASES OF THE KIDNEYS AND BLADDER. 

Or: 

B Urotropini 3 j 

Misce et fiant pulveres No. X. 
Sig.: Powder three times daily. 

Or: 

R Magnesii borocitrici 5 iss 

Sacchari lactis 3 iiss 

Olei limonis TTL xv 

Misce et fiat pulvere No. I. Dentur tales doses No. X. 

Sig.: Powder three times daily in a glass of sweetened 
water. 

Diet. The diet for uric acid stones is very im- 
portant. A mixed diet, with a preponderance of 
vegetables, fats, and carbohydrates, and occasion- 
ally a period of absolutely no meat, is indicated. 

Meats. Avoid all kinds of meats that are rich 
in cell nuclei, such as liver, brain, sweetbreads, 
and kidneys. The best method of preparation is 
by boiling, especially by putting the meat into cold 
water first. 

Fruits. Are exceedingly good for patients suf- 
fering with uric acid excess. The vegetable acids 
are changed to carbonates and combine with uric 
acid, forming urates, and these are much more solu- 
ble in the urine. 

The therapy of phosphatic deposits differs con- 
siderably from the foregoing. The urine is usually 
alkaline, and contains abundant crystals of triple 
phosphates. 

Mineral acids are indicated unless there is a co- 
existing hyperacidity of the stomach. 



NEPHROLITHIASIS. 97 

B Acidi pliosphorici or hydrochlorici 

diluti 3 iss 

Syrupi rubi idaei 3 iv 

Aquae destillatae q. s. ad 3 vj 

Misce. 

Sig. : Teaspoonful in a glass of water often enough to 
use the whole amount during the day. 

Where fermentation occurs in the digestive tract 
we must use the antifermentatives. 

B Sodii boratis gr. xx-gr. xxx 

Syrupi althaese 3 v 

Aquae destillatae q. s. ad 3 vj 

Misce. 

Sig.: Tablespoonful every two hours. 

Or: 

Ifc Urotropini 3 iiss 

Aquae destillatae 3 v 

Misce. 

Sig. : Tablespoonful in a glass of water to be taken gradu- 
ally during the day. 

Or: 

IJ Resorcinolis ( Merck ) gr. x 

Sacchari gr. x 

Olei menthae piperitae gtt. ij 

Misce et flat cachet No. I. Dentur tales cachets amylaceae 
No. XX. 

Sig.: Cachet three times daily. 

Always treat the faulty condition back of the 
calculus formation, such as dypepsia, hyperacidity, 
neurasthenia, etc. Have patient use large quan- 
tity of water to keep the kidneys flushed out. 

Surgery. Where a stone becomes lodged in the 
ureters and can not be passed either into the blad- 
der or back into the renal pelvis, or where a large 
stone forms in the pelvis too large to embark upon 



98 DISEASES OF THE KIDNEYS AND BLADDER. 

the journey to the bladder, surgery offers the only 
relief, and such cases should be turned over to a 
competent surgeon. 

Cystitis. 

Remember that cystitis is probably in all in- 
stances due to bacteria. The alkalinity of the urine 
is due to the power of many of the bacteria to 
break up urea into ammonia compound. Urinalysis 
shows alkaline urine as a rule; mucus, pus, and 
leucocytes more or less abundant; and crystals of 
the triple phosphates. 

Remember that the walls of the urinary bladder 
may become so thickened that it can be felt as a 
globular, hard tumor, and hypertrophied, muscular 
bands detected by the sound. 

Remember that when a stone is the cause of the 
cystitis, hematuria is more common; sudden, fre- 
quent interruption of the stream in micturition, due 
to obstruction of neck of bladder, and pain and 
strangury at the close of micturition. The explo- 
ration of the bladder with a sound will confirm the 
presence of the stones. 

Remember that the examination of the bladder 
with the cystoscope is important — not only in the 
diagnosis of cystitis, but the cause is frequently re- 
vealed. 

Remember that in tubercular cystitis without the 
presence of other organisms the urine is acid in re- 
action, as the tubercle bacilli do not decompose urea. 



cystitis. 99 

Treatment. 

Cystitis due to the presence of calculus can be 
cured only by removing the stone. Probably the 
best method is through the perineum. Never at- 
tempt to crush a stone in the bladder. 

Urinary antiseptics are indicated in all cases, and 
the best is hexamethylenamine (uro tropin), given 
in 5-grain doses three or four times a day. It les- 
sens the probability of complicating pyelitis. 

The bladder should be irrigated daily with hot 
boracic acid solution. 

Diet. Should consist principally of milk. Alco- 
hol, condiments, and drugs that irritate the bladder 
— such as cantharides or copaiba — must be pro- 
hibited. 

Catharsis. The bowels must be kept free, and 
salines are best, or oil enemata may be used. 

Pain. Hot amplications should be applied over 
the pubis. Cloths wrung out of hot water, and cov- 
ered with rubber cloth and bandage, may be used, 
or hot flaxseed poultice. In some cases the appli- 
cation of the ice bag affords greater relief. In case 
these local applications fail to give relief, a hypo- 
dermic of morphin gr. % and atropin gr. % 50 should 
be given into the skin of the abdomen. Supposi- 
tories may be used, as : 

Ifc Extracti opii gr. vj 

Extracti hyoscyaminse gr. v 

Olei theobromatis q. s. 

Misce et fiant suppositoria No. VI. 
Sig. : Insert 1 at bedtime. 



100 DISEASES OF THE KIDNEYS AIST) BLADDER. 

Or: 

B Pulveris opii gr. xi j 

Campliorse gr. xxx 

Extracti belladonnae gr. iij 

Olei tlieobromatis q. s. 

Misce et fiant suppositoria No. VI. 
Sig. : Insert 1 at bedtime. 

Or: 

I£ Ichthyolis 3 iss 

Aquae destillatse i j 

Misce. 

Sig.: Inject into the bladder, slowly, warm, three times 
daily, later once daily, as irrigation. 

Or: 

B Fluidextracti belladonnas V!{ xx 

Sodii biboratis 3 ij 

Acidi benzoici 9 j 

Tincturae opii camphoratae S iss 

Olei gaultheriae TIX xij 

Syrupi tolutani % i j 

Aquae destillatae § iv 

Misce. 

Sig. : Dessertspoonful in water four times daily. 

Or: 

B Forma tropini (Milliken) 3 iij 

Sig.: Teaspoonful three times daily after meals. 

In the chronic form, irrigation with silver solu- 
tion gives best results. Kaufmann's plan for nsing 
silver nitrate is best. Wash ont the bladder with a 
warm boracic acid solution and completely empty 
it. The catheter is then partly withdrawn, so that 
the silver solution may reach the prostatic portion. 
A solution of silver nitrate 1:2000 is injected and 
retained for three minutes, and then allowed to 



CYSTITIS. 101 

flow out spontaneously. If patient is very sensitive, 
this may be followed by salt solution. After two 
or three days this procedure is repeated, using 
1:1000 solution of silver nitrate. After this, 1:500 
solution may be used. The time between injections 
is gradually increased as improvement is noted. 

When the urine is acid the following combination 
may be administered internally: 

B Potassii acetatis 3 iv 

Liquoris potassii 3 j 

Fluidextracti uva ursi 3 iv 

Tincturae hyoscyaminae 3 iv 

Tincturae lupulini 3 iv 

Aquae gij 

Syrupi zingiberis q. s. ad 3 vii j 

Misce. 

Sig.: Tablespoonful in water after meals and at bed- 
time. 

Causal Therapy. Occasionally malarial infection 
will cause a severe acute cystitis, and quinin will 
give prompt relief when other forms of treatment 
fail. 



CHAPTER VH. 

DISEASES OF THE BLOOD. 

Chlorosis. 

Remember that this condition is due to a de- 
ficiency of hemoglobin, and is seen in girls at the 
age of profound sexual changes. There is no loss 
of subcutaneous fat, but, on the contrary, fat may 
be increased, due to deficient oxidation. 

Remember that puffiness of the face and swelling 
of the ankles may occur, and suggest nephritis, but a 
blood and urinary examination will disclose the 
cause. 

Remember that in some cases the cheeks may have 
a reddish tint, and on exertion the patient may 
complain of palpitation and breathlessness, sug- 
gesting disease of the heart or lungs. 

Don't mistake the systolic murmur heard at the 
apex for mitral disease. Cardiac enlargement is 
absent. 

The venous hum heard over the large veins in 
the neck is heard only in anemia. 

Remember that a drop of blood allowed to fall 
on a piece of white blotting paper often shows the 
anemia by its pale color, due to the reduction of 
hemoglobin. 

Remember the capricious appetite in these cases 
— the craving for unusual foods, especially acids, 

102 



CHLOROSIS. 103 

Remember that hyperacidity of the stomach and 
attacks of cardialgia, or severe paroxysmal head- 
aches, are quite common in chlorosis. 

Remember that the microscope shows small, pale- 
red cells, with but slight, if any, reduction in the 
number. 

Remember that in tuberculosis there is a pallor, 
but with cough; wasting, positive physical signs, 
rapid pulse; slight fever, recurring about the same 
time each day, also coexists; while the pallor of 
chlorosis is yellowish-green, with areas of pigmen- 
tation, and the eyes peculiarly brilliant, with sky- 
blue sclera. 

Treatment. 

Plenty of fresh air and good red beefsteak for 
chlorosis is an old adage that is hard to improve 
upon in the treatment. 

Rest in bed is imperative in the severe cases, and 
often better results are observed in milder attacks 
by requiring midday rest of the patient. 

Exercise should be moderate and carefully regu- 
lated. Those forms that are passive to the patient 
are best, as buggy riding or boating; then, as im- 
provement occurs, horseback riding and walking 
may be advised. 

Massage and dry rubs are excellent. Electricity 
is indicated, and should be used in the severer 
forms when neurasthenia is a pronounced factor. 

Diet must be nutritious. Proteids must be al- 
lowed liberally. It is best to feed frequently in 



104 DISEASES OF THE BLOOD. 

small quantities. Milk, to which is added cream, 
raw or slightly cooked meat, and eggs are excellent. 
Constipation must be overcome. Saline cathar- 
tics or pilulse aloes et f erri 3 to 5 a day may be used, 

B Fluidextracti rliamni purshianse aro- 

niatici 3 j 

Fluidextracti glycyrrhizse 3 i j 

Misce. 

Sig. : Teaspoonful night and morning with a glass of hot 

water. 

Where the constipation is due to atony of the 
bowels, and it most frequently is, the following is 
a good combination: 

Vf. Extracti rliamni purshianse 3 j 

Extracti nucis vomicae gr. viij 

Extracti physostigmatis gr. ij 

Extracti hyoscyaininse gr. v 

Misce et fiant pilulse Xo. XXX. 

Sig. : Pill night and morning. 

Iron is the only remedy with which to treat chlo- 
rosis. The mode of action is unknown. It is best 
to gradually increase the dose at the beginning and 
gradually decrease at the close. Of the prepara- 
tions to be used, those of U. S. P. are unexcelled. 
The vegetable iron preparations have no advantage, 
and the same may be said of peptonates. All are 
agreed that Blaud's mass will probably give best 
results. 

B. Pilulse ferri carbonatis ( Blaud ) . re- 
cently prepared gr. v 

Fiat pilula Xo. I. Dentur tales pilulse Xo. L. 
Sig.: Pill three or four times daily half an hour before 
meals. 

Blaud's pills may be given after meals, with in- 



CHLOROSIS. 105 

crease of dose; for instance, 1 pill three times daily 
for the first week, 2 dnring the second, 3 during the 
third, 2 during the fourth, and 1 during the fifth. 
It is well, where there is digestive disturbance, to 
give the following powder before meals: 

B Betanaphtolis gr. j 

Bismuthi subnitratis, 

Sodii bicarbonatis aa gr. iiss 

Misce et fiat pulvere No. I. Dentur tales doses No. XX. 
Sig. : Powder three times daily before meals. 

When severe attacks of gastralgia occur, it is 
usually made worse by iron and interferes with the 
treatment. Use an exclusive milk diet, hot cloths 
over the abdomen, and administer either bella- 
donna or silver nitrate. 

B) Argenti nitratis gr. x 

Kaolini gr. xlv 

Petrolati q. s. 

Misce et fiat massa et divide in pilulae No. L. 

Sig.: Pill before meals three times daily. 

Other forms of iron may be used: 

B> Ferri reducti 3 ss 

Pulveris glycyrrhizae 3 ss 

Extracti gentianae q. s. 

Misce et fiat massa et divide in pilulse No. XXX. 
Sig.: Pill three or four times daily. 

Arsenic is a useful drug in treating anemia, and 
may be advantageously combined with the iron: 

B) Ferri et ammonii citratis g j 

Liquoris potassii arsenitis 5 v 

Aquae menthae piperitae q. s. ad 5 vj 

Misce. 

Sig. : Half a teaspoonful after meals, gradually increasing 
dose until teaspoonful is taken. 



106 DISEASES OF THE BLOOD. 

Or: 

1^ Ferri et quininse citratis gr. 1 

Elixiris simplicis % ij 

Misce. 

Sig. : Teaspoonful three times daily. 

It is well to insist on plenty of water with the 
iron, especially iron in solution. 

Pernicious Anemia. 

Remember that this pathological condition makes 
its approach in so slow and insidions a manner that 
the patient is nnable to fix a date of onset of that 
languor which later becomes such a prominent 
symptom. 

Remember that, while the yellow color of the skin 
may indicate jaundice, the sclera of the eyes re- 
mains white and no bile pigment is fonnd in the 
urine. 

Remember that the initial symptoms are failing 
strength, anorexia, dyspepsia, and intestinal disor- 
der that may be so severe as to lead to a suspicion 
of grave pathological lesion in the alimentary 
canal, and loss of flesh, but the body maintains its 
plumpness, due to the accumulation of subcutane- 
ous fat. 

Remember that in some cases the nervous symp- 
toms are the first to attract attention — such as 
tingling in the fingers, pains in the back and limbs, 
or the signs of spastic paraplegia, tabes dorsalis, 
or peripheral neuritis. These symptoms may be 
so pronounced that months, or even years, elapse 
before the blood condition is suspected. 



PEENICIOUS ANEMIA. 107 

Remember the circulatory disturbances — such as 
palpitation, faintness or actual syncope, throbbing 
in the head, buzzing noises in the ears. 

The pulse is quickened and greatly affected by 
slight exertion. A blowing systolic murmur is 
heard over the whole cardiac area, but loudest in 
the second left intercostal space close to the 
sternum. That it is of hemic origin is proven by 
the presence of a similar murmur in the large ar- 
teries and a loud hum in the jugular veins. The 
carotids pulsate violently and often a thrill may 
be felt over them. 

Remember that a positive diagnosis can be made 
only by examination of the blood, which will pre- 
sent the following characteristics: clotting less 
readily than normal; a great reduction in the num- 
ber of the red cells; the presence of pathological 
forms of cells, as poikilocytes and megolocytes; the 
hemoglobin percentage is reduced, but the color 
index is high. There is no leucocytosis, but in some 
cases there is an increase in the number of lympho- 
cytes. 

Treatment. 

The following gives a concise, but complete, out- 
line of the treatment: first, a diagnosis; second, 
rest in bed; third, plenty of fresh air, and, if possi- 
ble, in the open air; fourth, all the good food the 
patient can take; fifth, arsenic. 

Fowler's solution is probably the best form in 
which to administer the arsenic. Give it in increas- 



108 DISEASES OF THE BLOOD. 

ing doses, beginning with 3 minims three times 
daily and increase 1 minim each week until 15 or 20 
minims are given at a dose, or until toleration is 
reached. 

Normal saline solution by hypodermoclycis or 
into the vein is beneficial if given rather frequently. 
It checks the destruction of red cells by the blood 
serum. 

Mouth should be cleansed thoroughly daily with 
some antiseptic mouth wash. Iron appears to be of 
benefit in a few cases. 

Salol is given by some on the theory that the 
disease is caused by absorption of toxins from the 
bowels. 

Arsenic may be given hypodermatically as sodium 
arsenate gr. % , or atoxyl (meta-arsenic acid anilid), 
using 6 minims of 15-percent or 20-percent solu- 
tion. Warm the solution, to be sure of complete 
solution of the atoxyl. The dose is increased 6 min- 
ims daily until 5 grains of atoxyl are given and con- 
tinued for four weeks, then reducing the injections 
to two a week, then one a week, then intermit the 
treatment for from six to eight weeks. 

Remember that serious results have followed the 
hypodermatic use of arsenic. Fowler's solution, di- 
luted with 2 parts of water, may be used. 

Leukemia. 

Remember that the onset is insidious, and the 
patient may seek advice for a progressive enlarge- 



LEUKEMIA. 109 

ment of the abdomen, enlarged glands, or for palpi- 
tation and dyspepsia, or for severe epistaxis. 

Remember that hemorrhage is exceedingly com- 
mon, and a fatal hematemesis may be the first 
symptom. 

In the splenomedullary form the enlargement of 
the spleen is pronounced, extending downward and 
to the right. Its notched, sharp border usually 
identifies the tumor as splenic. Splenic friction can 
often be heard and felt over the tumor, and the 
enlarged spleen may lift the heart to the fourth 
costal space and cause dyspnea from its size. Some- 
times tenderness over the sternum and the long 
bones can be elicited. 

Remember that there are four cardinal findings: 

1. Enlargement of lymph glands, spleen, and 
tonsils. 

2. Hemorrhage. This is the most characteristic 
and frequent. It may occur into the skin, retina, 
from mucous membranes, or into viscera, as spleen 
or brain. 

3. Necrosis, occurring in the infiltrated foci of 
the mouth. This condition is very suggestive. 

4. Lymphemia. This is the deciding factor, and 
no positive diagnosis can be made without blood 
examination. The lymphocytes are greatly in- 
creased, and may constitute from 92 percent to 98 
percent of the leucocytes. The ratio between the 
red and white cells changes, and may be as 1:2 
or 1:1. 



110 diseases of the blood. 

Treatment. 

A good diet, fresh air, rest, and abstaining from 
mental worry are the important general conditions. 

Quinin should be given in cases with a malarial 
history. 

Phosphorus is given by some; best given in pill. 

Arsenic is the best agent at our command to com- 
bat this condition. It must be given in increasing 
doses and in large amounts. Fowler's solution is 
the form mos»t often used. Begin with 5 drops three 
times daily and increase 1 drop daily until 40 or 50 
drops are taken. If slight diarrhea is caused by 
the arsenic, give paregoric with it and occasionally 
a slight purgative to prevent accumulation. 

Arsenious acid may be used, but should always 
be combined with black pepper, so that absorption 
will be hastened. The drug may be used hypoder- 
matically, as in pernicious anemia. X-ray is often 
used, and in a few cases with apparent benefit. 
When it is used it should be employed cautiously, 
as deaths have occurred suddenly, with the appear- 
ance of toxemia from cell destruction. 

Pseudoleukemia (Hodgkin's Disease). 

Remember that chronic tonsillitis of several 
months' standing may precede Hodgkin's disease. 
In all cases of enlargement of cervical glands the 
teeth should be thoroughly examined; this is espe- 
cially true in the young. 

Remember that anemia is not, as a rule, severe, 



PSEUDOLEUKEMIA. Ill 

and occurs late in the disease, and that an exam- 
ination of the blood usually does not show any dis- 
proportion of cells. 

Remember that the temperature curve, if fever 
exists, is rather suggestive of a toxemia because of 
its irregularity, and is often accompanied by chills 
and sweats. 

Remember that the enlargement of the axillary 
and inguinal glands strongly indicates the condition, 
but unfortunately does not occur early. Pressure 
symptoms may be caused by the enlarged glands, 
the axillary causing pain and swelling in the hands 
and arms, and the inguinal great pain and swelling 
of the feet. 

Remember that bronzing of the skin may occur 
and an obstinate pruritus. Eecurring boils are 
frequent. 

Remember that tuberculous glands of the neck 
very closely simulate this condition. 

1. The differentiation should be made by remov- 
ing one of the glands under cocaine and examine 
it. The histologic changes in the gland in tuber- 
culous infection are distinct and the bacilli may be 
found. 

2. Tuberculin should be used if the patient has 
no fever. In early tubercular adenitis the reaction 
is prompt. It should be used continuously, and a 
daily record kept of the temperature. 

3. Periadenitis is very common in tuberculous 
glands, and the skin becomes adherent and the 



112 DISEASES OF THE BLOOD. 

glands are not movable. Eventually some of the 
glands break down and discbarge. 

Remember that tbe blood count will decide for or 
against leukemia. 

Treatment. 

Operation for the removal of the enlarged glands 
should be advised when the superficial glands of 
one side of the neck are involved. Even when the 
glands of both sides are involved, if there are no 
mediastinal glands involved, operation is advisable. 

X-ray in selected cases does some good. The 
glands may be reduced in size, but it is questionable 
whether a cure is effected. 

Morphin should be used to relieve pressure pains. 

Tonics, as quinin, iron, and codliver oil, should 
be used. 

Arsenic in the form of Fowler's solution gives 
the best results. It should be given in increasing 
doses, beginning with TTt iij-irt v, until the point of 
toleration is reached. 

Iodin, locally to the glands, appears to be harmful. 

Injection into the glands is not beneficial. 

Hypodermatic injections of sodium cocodylate 
may be used instead of arsenic when it irritates 
the bowel. May be combined as follows: 

B Sodii cocodylatis gr. xxv 

Cocainae hydrochloride gr. ss 

Sodii cliloridi gr. j 

Aquse destillatae q. s. ad 3 j 

Misce et fiat solutio. 

Sig. : Inject 15 to 30 minims daily. 



PURPURA. 113 

Purpura. 

Remember that this may occur as a symptom in 
various conditions, as in many infectious diseases 
— such as scarlatina, sepsis, measles, variola, etc.; 
or it may be of a toxic nature — as in nephritis, cho- 
lemia, or in the use of quinin, mercury, etc. Often 
it occurs in the aged in malignant tumors, leukemia, 
pseudoleukemia, and pernicious anemia. 

Remember that the coagulating time of the blood 
is greatly lengthened. The eruption is usually 
macular, but may be papular or urticarious. 

Remember that it seldom occurs on the face, but 
usually confined to the extensor areas of the ex- 
tremities, especially the legs. 

Remember that in purpura rheumatica the joints 
are involved. In most cases tonsillitis, with fever, 
muscular pains, and colic are initiatory symptoms. 
Sloughing of the tonsil has occurred. The joints 
most commonly involved are knees, ankles, or 
elbows. 

Remember that the purpura may precede or fol- 
low the joint symptoms, and various forms of the 
eruption occur, as macular, urticarious, or erythem- 
atous. 

Remember that there is a great tendency to 
hemorrhage from mucous surfaces, as nose, mouth, 
alimentary tract, or vagina. These hemorrhages 
may be serious and even fatal. 

The purpuric spots in the skin do not disappear 



114 DISEASES OF THE BLOOD. 

on pressure, and the best way to observe this is 
by pressing over the spot with a glass slide. 

Treatment. 

The diet should be carefully watched. All acids 
and acid fruits, crabs, lobsters, and egg albumen 
(Wright's decalcifying agents) should be avoided. 

Cathartics should be used to keep the bowels mod- 
erately free. 

Calcium lactate, or chlorid gr. x-gr. xxx, should 
be given, so that the coagulating time of the blood 
may be decreased. 

I£ Calcii lactatis gr. xx 

Misce et fiat charta No. I. Dentur tales doses No. XII. 
(Waxed paper.) 
Sig. : Powder four times daily. 

Or: 

B Sodii sulphocarbolatis 3 iij 

Stypticini ( Merck ) gr. xv 

Aquae menthae piperita? 3 iij 

Syrupi simplicis 3 j 

Aquae % i j 

Misce et fiat solutio. 

Sig.: Tablespoonful every four hours. 

In rheumatic forms the antirheumatic remedies 
must be administered. 

IJ Potassii iodid © ij 

Sodii salicylatis 3 ss 

Syrupi simplicis 3 iv 

Aquae q. s. ad £ ij 

Misce. 

Sig.: Dessertspoonful every four hours. 



PURPURA. 115 

Where a good general tonic is needed, the follow- 
ing is good: 

B Arseni trioxidi gr. j 

Quininse muriatici & ivss 

Ferri sulphatis exsiccati o j 

Extracti nucis vomicae gr. x 

Misce et fiant pilulae No. LX. 

Sig. : Pill after each meal. 

Gelatin may be nsed, injecting 1% ounce of a 
10-percent solution into the gluteal region to check 
hemorrhage. 



CHAPTER Vin. 

DISEASES OF THE DUCTLESS GLANDS. 

Addison's Disease. 

Remember that the onset is insidious, the patient 
gradually losing strength and energy. Gastric dis- 
turbances finally cause him to seek relief. 

Remember that, while pigmentation is an im- 
portant sign, it is variable, both as to the time of 
its appearance and in its degree. Usually follow- 
ing the constitutional symptoms, it may precede 
them or it may not occur until shortly before the 
fatal termination. The extent of pigmentation is 
variable, and may be universal, but it is usually 
partial. It is usually seen first on the face, neck, 
and back of the hands and fingers. The shade of 
color varies from lemon-yellow to dark-brown or 
black; usually darker on exposed parts and natur- 
ally pigmented portions. 

Remember that pigmentation is not pathogno- 
monic of Addison's disease. The following must be 
excluded: 1, abdominal growths, as tubercle, cancer, 
or lymphoma; 2, uterine disease and pregnancy; 3, 
hypertrophic cirrhosis and diabetes; 4, melanotic 
cancer and exophthalmic goiter; 5, pernicious ane- 
mia and prolonged use of arsenic. 

The occurrence of fainting fits, nausea, gastric 
irritability, and asthenia are stronger indications 
of Addison's disease. 

116 



Addison's disease. 117 

Remember that asthenia is probably the most fre- 
quent and important symptom. Easily tired at first, 
the patient finally becomes unable for any exertion 
of either mind or body. 

Remember that there is no emaciation accom- 
panying the muscular feebleness. There may be ex- 
treme degree of muscular prostration, while the 
muscles feel firm and hard, with no emaciation, and 
therein lies the distinctive quality of asthenia in 
Addison's disease. This loss of muscular power 
extends to the cardiac muscle, as is shown by the 
small, extremely soft, and compressible pulse. 

Remember that, as a large percentage of Addi- 
son's disease is due to tubercular degeneration of 
the glands, in doubtful cases the tuberculin test may 
be used. 

Treatment. 

Rest in bed is imperative because of the exhaus- 
tion and danger of fatal syncope. 

Diet must be nutritious and liberal. 

Tonics are indicated. Arsenic and strychnin are 
best. 

For the nausea and vomiting, creosote, phenol, 
ice, and hydrocyanic acid should be given. 

Diarrhea is best controlled by large doses of bis- 
muth. 

For vomiting and diarrhea the following is good : 

B- Bismuthi subnitratis 3 iv 

Creosoti (Beechwood) TIX v 

Aquae menthse piperita g ii j 

Misce. 

Sig. : Teaspoonful every two or three hours. Shake well. 



118 DISEASES OF THE DUCTLESS GLANDS. 

Organotherapy gives good results in many cases; 
some are apparently cured. The medullary portion 
of the suprarenal gland is the part used. The raw 
gland, partially cooked, or the glycerin extract may 
be used. 

$ Suprarenal gland desiccated (U. S. 

P.) 3ij 

Extracti nucis vomicae gr. iij 

Misce et fiant capsular No. XXIV. 

Sig. : 1 or 2 capsules three times daily. 

Solution of adrenalin chlorid may be used hypo- 
dermatically — a dram of 1:1000 solution injected 
every other day. 

Exophthalmic Goiter. 

Most common in women between puberty and the 
menopause. 

Remember that there are four cardinal symptoms 
that render a diagnosis positive when present, and a 
positive diagnosis is impossible unless some of them 
are found. They are: goiter, exophthalmos, tachy- 
cardia, and tremor. 

The goiter, as a rule, is small and the right side 
of the gland is more prominent. The tumor is soft 
and uniform, but occasionally may be irregular and 
contain rounded or nodular masses that are hard. 
Pulsations can usually be seen in the gland and a 
murmur heard over it. On palpation a systolic 
thrill may be felt. The goiter rarely produces 
pressure symptoms, and it varies in size at different 
times. 



EXOPHTHALMIC GOITER. 119 

Remember that exophthalmos is present and often 
early. It may be unilateral. The amount of pro- 
trusion varies, and this protrusion produces the fol- 
lowing signs: 

1. Grafe's Sign. The upper lids lagging behind 
in the downward movement of the eyeballs, and 
the sclerae become visible between them and the 
cornea. 

2. Stellwag's Sign. The widening of the palpe- 
bral fissure. This retraction of the upper lids 
causes a white ring of sclera to be seen all around 
the iris. 

3. Diminished frequency of winking. 

4. Mobius' Sign. The inability to converge for 
near-by objects. An attempt causes a sense of 
strain, but no double vision. This sign is not al- 
ways present. 

5. Joffroy's Sign. The head is bowed forward 
and the patient asked to look up without changing 
the posture. The forehead is not wrinkled, as oc- 
curs in health. 

Tachycardia is not only prominent, but one of the 
most constant signs. The rate of the pulse may be 
very high, but there is no irregularity, except to- 
ward the close. 

Remember that the area of cardiac pulsation is 
increased and the action is heaving and forcible. 
The large arteries of the neck throb and a capillary 
pulse is readily seen. Frequently a pulse can be seen 
in the veins of the hands. 



120 DISEASES OF THE DUCTLESS GLANDS. 

Remember that the tremor is most always found, 
and may be the chief trouble of complaint by the 
patient. It varies in degree, and may be discovered 
by the physician only after careful observation. 
The tremors usually run from eight to ten per sec- 
ond, and may be best observed by the patient 
standing, hands and fingers extended, and a piece 
of paper laid across the back of the fingers. The 
tremor is made worse by excitement and worry. 

There are some signs that are of secondary im- 
portance in making a diagnosis. The most promi- 
nent are the following: 

1. Emaciation is the most constant. The loss of 
strength is dependent upon the emaciation. 

2. Sweating is frequent and often a troublesome 
symptom. The falling of the hair is due to its dis- 
turbed nutrition. A dry cough is frequently ob- 
served, due to pressure upon the trachea. 

3. Edema of the feet may occur, and is due to the 
cardiac weakness. 

4. A change in the mental condition will often be 
the earliest sign. The patient becomes irritable, 
excitable, emotional, fidgety, and restless; is unable 
to concentrate his mind and longs for continuous 
changes. 

Treatment. 

Rest, free from worry and anxiety, is imperative, 
and in severe cases it is best to confine the patient 
to bed. The quietude of a country place, where 



EXOPHTHALMIC GOITER. 121 

there is plenty of good, fresh air and sunshine, is 
the best place. 

Diet must be abundant and mixed. It is better 
to somewhat limit the amount of meat, but plenty 
of proteids must be given because of the large 
amount of nitrogen eliminated. Stimulants — as 
coffee, tea, alcohol, chocolate, and condiments — 
must be prohibited. 

Hydrotherapy often gives good results. The 
baths may be given at home. The only thing to 
keep in mind is to avoid all forms of stimulation, as 
cold douche along the spine or hot pack, until per- 
spiration begins. In all forms the bath should be 
sedative and cold kept to the head. 

Electrotherapy is recommended by some. Gal- 
vanism is the form used. The positive pole is placed 
under the angle of the lower jaw with moderate 
pressure. The negative electrode is placed on the 
neck at the height of the lowest cervical vertebra. 
The strength of the current, which is gradually in- 
creased and then gradually decreased, is applied 
for two to three minutes. Both sides of the neck 
should be treated in this way. 

Medication. If chlorosis or anemia be present, 
iron and arsenic should be used. 

For marked nervous symptoms sodium or stron- 
tium bromid should be exhibited. Or camphor 
monobromate may be tried, as: 

B Camphorse monobromatae gr. v-gr. x 

Sacchari lactis gr. ii j-gr. v 

Misce et fiat pulvere No. I. Dentur tales pulveres No. XX. 
Sig. : Powder three times daily. 



122 DISEASES OF THE DUCTLESS GLANDS. 

Forcheimer's method gives excellent results and 
consists in giving qninin hydrobromate gr. v in gela- 
tin-coated pill four times daily, and, if no improve- 
ment within forty-eight hours, he adds ergo tin gr. j. 
He claims a cure in from 70 to 90 percent of cases. 
The time of treatment varies from four months to 
three years. Cromium sulphate gr. v three or four 
times daily often gives surprisingly good results. 

Beebe and Kogers have prepared a serum by in- 
jecting animals with pathological glands. They 
claim remarkably favorable results, but it must be 
used early. After the profound anatomical changes 
occur in other organs it appears to be less potent. 

Sodium phosphate in % to 2 drams daily acts 
beneficially, especially upon the nervousness. 

Ortner highly recommends dilute sulphuric acid, 
10 drops three times daily, for the vasomotor dis- 
turbances so often occurring. 

Tincture of convallaria and belladonna in full 
doses will often quiet the heart and reduce the pulse 
rate. 

Iodin in any form, locally or internally, should be 
studiously avoided in malignant goiter. Theoretic- 
ally, the same advice applies to thyroid extract. 

Surgery, while responsible for some sudden 
deaths from acute cardiac dilatation, does in some 
cases offer relief, or even a cure. 

Milk from thyroidectomized goats has given re- 
sults in a few cases. Chemists have produced a sub- 
stance from the milk called rodagen, and is said 



EXOPHTHALMIC GOITER MYXEDEMA. 123 

to contain 50 percent of the active constituent of 
the milk and 50 percent milk sugar. From 1 to 3 
drams are given daily. Patients sleep better and 
are less nervous while taking it. 

Merck prepares a serum from thyroidless sheep 
that is said to be useful, but the expense of both 
of these preparations limits their use. 

Myxedema. 

There are two forms, and the division relates only 
to age, as both are caused by the atrophy of the 
thyroid. The forms are cretinism, occurring in 
children, and myxedema of the adult. 

Remember that it is difficult to diagnose cretin- 
ism prior to the first year. 

Remember that a child that stops growing, and 
there is lack of proportion between the various 
parts of the body, so that there is a plump head, 
a short and deformed body, and thick, "pudgy" 
arms and legs, should strongly suggest cretinism. 
The large head is flat at the top, narrow in front, 
and broad behind. The face is broad and expres- 
sionless. The forehead is low and broad. The eyes 
are dull and appear to be half closed, caused by the 
swollen lids, and are wide apart. The nose is stub- 
by, depressed at the root, nostrils widely opened, 
and the alae thickened. The ears are thickened. 
The lips are thick and protruding. The tongue is 
swollen and protrudes. 

Remember that the skin is dry and harsh, and ap- 



124 DISEASES OF THE DUCTLESS GLANDS. 

parently dropsical, but will not pit in cretinism, 
while in rickets there are the sweating head, cranio- 
tabes and swollen, tender joints. 

Remember that mental dullness, backwardness 
about learning to talk and walk, and the disturbance 
of the special sense of taste and hearing character- 
ize cretinism. 

Myxedema occurs more frequently in women and 
between the fifteenth and forty-fifth years — the 
child-bearing period. 

Remember that the onset is insidious, but languor, 
undue sensitiveness to cold, with slight auditory and 
visual hallucinations, and swollen eyelids mark the 
onset of athyria. 

Remember that there are some characteristic 
signs that are found in no other conditions, and the 
following are the most prominent : 

1. Dense, inelastic swelling of the subcutaneous 
tissues, which do not pit upon pressure. It is 
most abundant where subcutaneous tissues are lax, 
and thus gives a peculiar appearance to the face and 
hands. 

2. A change in the facial expression, due to the 
obliteration of the lines of expression — the swollen 
eyelids, the transverse wrinkles of the forehead, the 
thickened and enlarged nose, and swollen lip. 

3. The swollen and shapeless hands and feet. 

4. Increase of size and body weight. 

5. Subnormal temperature. 

6. Mental dullness and muscular weakness. 



myxedema. 125 

Treatment. 

There is nothing else in our therapeutics that is 
so satisfactory as the treatment of this condition. 

The thyroid gland, or extract made from it, may be 
given. It is better to give the extract put up in 
tablets. The dose at the beginning should be small 
and cautiously increased. Whenever the following 
symptoms appear, the treatment must be stopped 
for a few days: these are palpitation, faintness, 
dyspnea, anorexia, nausea, vomiting, nervousness, 
tremor, and sense of fear. It is better to begin 
with from 1 to 2 grains and gradually increase until 
from 15 to 30 grains are taken. 

Ifc Tablet thyroidin (Merck) aagr. ij 

No. C. 

Sig. : Tablet three times daily, gradually increasing until 
four are taken. 

Or: 

Ifc Thyroidin gr. xxx-gr. xl 

Arseni trioxidi gr. j 

Extracti nucis vomicae gr. iij 

Misce et fiant pilulse No. LX. 

Sig.: Pill three times daily, gradually increasing until 
three or four are taken. Interrupt treatment occasionally. 

In infantile form or cretinism Forcheimer's rule 
of dosage is good, and is as follows: the adult dose 
is taken at 5 grains and the dose for an infant is 
obtained by taking one-twentieth of the fraction ob- 
tained by dividing the age in months by twelve. 
Thus for a child four months old, %o of %2 of 5 equal 
M.2J hence the dose would be gr. V 12 for a child four 



126 DISEASES OF THE DUCTLESS GLANDS. 

months old. He cautions against even the small 
dose and advises to begin by giving it once a day, 
then twice, and finally thrice. The nntoward symp- 
toms in children are restlessness, poor sleep, loss 
of appetite, and irritability. It should not be 
pnshed nntil the graver symptoms of rapid pulse, 
vomiting, or collapse occur. 



CHAPTER IX. 

DISEASES OF THE VASCULAR SYSTEM. 

Pericarditis. 

Remember that many of the idiopathic varieties 
are tubercular in origin, and that rheumatism is 
the most frequent cause of the secondary variety. 

Remember that the acute fibrinous stage may or 
may not be followed by an effusion into the peri- 
cardium. 

Remember that in the early, or fibrinous, stage 
auscultation furnishes the only conclusive evidence, 
and that the friction sound thus heard possesses the 
following characteristics : 

1. It is double, and corresponds to the systole and 
diastole of the heart. 

2. It is a to-and-fro murmur, and outlasts the first 
and second sounds of the heart. 

3. The sound has a peculiar rubbing or grating 
quality, or it may be compared to creaking of new 
leather. 

4. It is best heard over the right ventricle — the 
fourth and fifth interspace, at the left sternal mar- 
gin — and appears to be superficial or close to the 
stethoscope. 

5. Variability. It may be heard at one time and 
not at another. 

6. The murmur may be intensified by pressure 
upon the stethoscope. 

127 



128 DISEASES OF THE VASCULAR SYSTEM. 

7. There are no definite lines of transmission, as 
in endocardial murmurs, and is usually heard over 
a limited area at the border of the sternum. 

Remember that when effusion occurs, the friction 
sound disappears over the body of the heart, but 
may be heard at the base. There is an accentuation 
of the second pulmonic sound, while the first is ob- 
scure. The cardiac action is rapid and frequently 
arhythmic. 

Remember that in well-developed cases of effu- 
sion the symptoms may be grouped as constitu- 
tional and local. 

Constitutional Signs. Fever, restlessness, dysp- 
nea, anorexia, pallor, insomnia, melancholia, with 
suicidal tendencies. 

Pain varies from sharp, lancinating to dull, ach- 
ing, and is made worse by pressure over the area 
with the stethoscope. 

The dyspnea varies with the amount of effusion — 
from breathlessness, when the patient prefers to lie 
on the left side; to air hunger and extreme dyspnea, 
when he is obliged to be propped up in bed. 

The pulse is rapid, small, and may be arhythmic. 
It may be obliterated during inspiration in large ef- 
fusion — pulsus paridoxicus. It may be smaller in 
the left than right radial artery. 

Physical Signs. Inspection shows precordial 
prominence, and widening and bulging of the lower 
intercostal spaces. Palpation shows feeble cardiac 
impulse. 



PERICARDITIS. 129 

First rib sign is found where there is a large 
amount of effusion. It produces an elevation of the 
clavicle, with a bulging of the left retroclavicular 
space, so that the first rib can be easily palpated to 
the sternum. 

Percussion yields the most important sign, but 
a certain amount of effusion is necessary before it 
can be detected. 

Rotch's Sign. With a normal or dilated heart 
the vertical border of the heart forms a right angle 
with the upper transverse hepatic dullness. When 
effusion occurs, this angle is replaced by a more or 
less curved line. 

Triangle Sign. When effusion takes place into 
the pericardium, it collects in the most dependent 
portion of the sac, and as it increases it widens the 
area of dullness. This forms a triangle, with the 
base downward and apex up in the precordial 
region. The right leg of the triangular dullness 
may reach to or beyond the right border of the 
sternum, while the left leg may extend to the left 
anterior axillary line. 

It is important to remember that cardiac dullness, 
particularly the left leg of the triangle, extends be- 
yond the apex beat, which is also pulled downward 
and to the left. 

Remember that the pressure of the effusion pro- 
duces symptoms in other organs, but the most im- 
portant ones are dysphagia, paralysis of the vocal 
cords, vomiting, and singultus. 



130 DISEASES OF THE VASCULAR SYSTEM. 

Remember that, in differentiating between cardiac 
effusion and cardiac dilatation, an undulatory im- 
pulse seen or felt in two or more interspaces; dis- 
tinct, though feeble, heart sounds, valvular in char- 
acter, but having the fetal rhythm; and changes 
in the upper border of dullness by postural changes, 
are strongly suggestive of effusion. 

Remember that in left-sided pleural effusion the 
heart is displaced to the right, the cardiac impulse 
and valvular sounds are distinct, and the area of 
flatness extends around the base of the chest. 

Treatment. 

Remember that rest in bed is imperative, so that 
the work of the heart may be lessened. 

Diet should be liquid and principally milk. If 
the case extends over a period of two weeks, it is 
better then to add to the diet, so that the nutrition 
of the cardiac muscle will be maintained. 

Medicinal. If the pericarditis is of rheumatic 
origin, sodium salicylate is indicated. It should be 
given with potassium bicarbonate. Ice bag should 
be applied over the cardiac region to quiet the heart. 
Morphin, given hypodermatically, is often beneficial 
to relieve dyspnea. Tincture of aconite nri iij-tii v 
may be given for the same purpose. Amorphous 
aconitin gr. M.30, given every half to one hour to 
effect, is much better. Digitalis is the best aid in 
this as in other cardiac affections. It may be given 
combined as follows: 



PERICARDITIS. 131 



B Potassii acetatis 3 ij 

Spiritus setheris nitrosi 3 ij 

Tincturae digitalis 3 j 

Aquae menthae . piperita^ . . . q. s. ad 5 ij 

Misee. 

Sig. : Teaspoonful every four hours. 



Or: 



R. Potassii citratis 3 ij 

Inf usi digitalis ( fresh leaves ) . . . . 3 i j 

Aquas menthae piperita^ . . . . q. s. ad g vj 
Misce. 
Sig.: Tablespoonful every four hours. 

Or: 

R Tincturae digitalis, 

Tincturae scillae aa 3 i j 

Misce. 

Sig.: 20 to 30 drops three times daily. 

If constipation exists, mild laxatives should be 
used. Should the fluid persist, it then becomes nec- 
essary to tap the pericardium and draw it off. 

The technic, according to Curschmann, is as fol- 
lows: The place chosen is the fifth intercostal 
space in the left mammary line, a point midway 
between the apex beat and left border of absolute 
dullness; or Bristow's choice, immediately to the 
left of the sternum in the fourth or fifth space, 
which latter location avoids wounding the artery 
and pleura. The skin is properly cleansed and may 
be anesthetized, and a small trocar and cannula 
pushed through the chest wall and pericardium. 
When the point passes through the pericardium, 
the sense of resistance ceases. A Potain aspirator 



132 DISEASES OF THE VASCULAR SYSTEM. 

may be used. The fluid should be allowed to flow 
out very slowly aud the patient watched carefully, 
as sudden death sometimes occurs. After the fluid 
is all withdrawn, a collodion dressing is applied. 
To lessen the troublesome adhesions that so often 
occur after withdrawing the fluid, it is well to give 
digitalis at intervals until recovery. 

Acute Endocarditis. 

Remember that this condition is most always, if 
not always, due to some infectious process, and that 
rheumatism, chorea, pneumonia, and scarlatina are 
exceedingly apt to produce it. 

Remember that in simple endocarditis two things 
should be watched for, announcing its onset. In or- 
der of importance, they are pulse rate and tempera- 
ture. The rapid pulse may be irregular and palpi- 
tation be complained of. 

Remember that the earliest sign that ausculta- 
tion reveals is a slight roughening of the " first 
sound. ' ' Later there may or may not be a murmur 
— systolic, or diastolic in time. 

Remember that reduplication and accentuation of 
the pulmonic second sound is frequent. 

Remember the more pronounced general symp- 
toms — as irregular, rapid, feeble pulse; faintness, 
oppression, pallor, perspiration, and precordial pain. 

Malignant Endocarditis. 

Remember that the history of the case is all-im- 
portant in the diagnosis. 



MALIGNANT ENDOCARDITIS. 133 

Remember that we have two groups of symptoms 
— those of the primary disease and those of the 
endocarditis — and the clinical picture varies ac- 
cording to the domination of the one or the other 
group. To the first group belong the irregular 
fever, sweating, anemia, delirium, and loss of 
strength. To the second belong the air hunger 
symptoms, as dyspnea, orthopnea, palpitation, and 
irregular, but frequent, cardiac action. 

Remember that emboli are common, and the signs 
vary with their location. 

Remember that chills, fever, and sweat may occur 
periodically in some cases, and strongly suggest 
malaria, but the absence from the blood of the 
malarial parasite is conclusive. 

Treatment. 

Rest in bed, free from worry, in all infectious dis- 
ease likely to be complicated by endocarditis, is the 
best prophylaxis and becomes imperative after its 
onset. 

Cold over the cardiac area or a mustard plaster 
is good to quiet the rapid heart action. The diet 
should be liquid and nutritious. If rheumatism be 
the cause, salicylate and alkalies should be given; 
this is extremely important in children, as the joint 
symptoms are so mild. With rapid, weak heart, 
digitalis should be used. If there is cardiac irrita- 
tion manifested by tachycardia and pain in the pre- 
cordial region, it is well to combine aconite with 
it, as: 



134 DISEASES OF THE VASCULAR SYSTEM. 

B Tincturee digitalis 3 iiiss 

Tincturse aconiti 5 iss 

Misce. 

Sig. : 15 drops three or four times daily. 

Eicliorst claims to have cured a case by a com- 
bined use of quinin and bichlorid of mercury, as 
follows: 

B Quininse hydrochloridi gr. lxxv 

Hydrargyri chloridi corrosivi gr. iij 

Pulveris glycyrrhizae 3 ss 

Extracti gentianae q. s. 

Misce et fiat massa. Divide in pilulse No. XX. 

Sig.: 3 pills daily after eating. 

Collargol (Crede) is claimed by Ortner to be the 
best remedy in all cases of sepsis, pyemia, and bac- 
teremia. If the ointment be used, the skin over the 
area to be rubbed is cleansed with alcohol and 
dried. Then 45 grains of 15-percent unguenti col- 
largoli rubbed in carefully until the skin shows a 
grayish-brown tinge. 

Rectal Use. 

B Collargoli gr. xv 

Aquae destillatae 3 vj 

Sig. : The bowel is first irrigated with a cleansing enema 
in the morning and half of the above amount is run into 
the rectum slowly, and the balance is given in the evening. 

Potassium iodid is recommended to stimulate ab- 
sorption of the inflammatory product on the valves 
and prevent its conversion into fibrous tissue. It 
should not be given until subsidence of the inflam- 
matory condition, and then administered cautiously 
and alternated with digitalis. 



VALVULAR DISEASE OF THE HEART. 135 

A saturated solution may be used, or the follow- 
ing: 

IJ Potassii iodidi gr. xx 

Potassii bicarbonatis 9 ij 

Spiritus ammonii aromatici 3 ij 

Tincturse cinchonse compositse 3 v 

Aquse q. s. ad % iv 

Misce. 

Sig. : Tablespoonful three times daily. 

Valvular Disease of the Heart. 

Aortic Incompetency. 

Remember that this is the lesion of the athlete 
and occurs in able-bodied, vigorous men. 

Remember that, etiologically, there are three 
groups : 

1. Those of congenital malformation. 

2. Those due to endocarditis. 

3. Those caused by arteriosclerosis. 

The last is by far the most common, and is usually 
associated with a history of prolonged muscular 
strain. 

Remember that the earliest signs are usually 
those due to arterial anemia, as headache, dizziness, 
flashes of light, and a feeling of faintness on sudden 
rising. 

Remember that pain in the precordial region may 
be severe, and is often transmitted up the neck and 
down the arm. 

Further failure of compensation produces dysp- 
nea, but rarely cyanosis, hemoptysis, and edema of 
the feet. 



136 DISEASES OF THE VASCULAK SYSTEM. 

Remember that mental disturbances are very com- 
mon in this lesion, snch as delirium, hallucinations, 
and morbid impulses, with suicidal tendencies. 

Remember that anasarca is rare, while sudden 
death is more common than in the other valvular 
lesions. 

Remember the value of examining the arteries 
in this condition. The following signs are more or 
less distinctly characteristic of aortic incompe- 
tency : 

1. The visible pulsations in the peripheral vessels. 

2. The pulsation is accompanied by a character- 
istic jerking. The aorta may lift the epigastrium 
with each pulsation. 

3. Corrigan's, or water-hammer, pulse. The pulse 
wave strikes the finger with a quick, jerking im- 
pulse and immediately collapses. The peculiarities 
of the pulse may be emphasized by grasping the 
arm above the wrist and holding it up. 

4. Eetardation of the pulse. There is an appre- 
ciable interval between the heart beat and the radial 
pulse. 

5. Capillary pulse, seen in the finger nails; or, by 
drawing a line upon the forehead, the margins of 
the hyperemia alternately blush and pale. 

It is important that you auscultate over the 
carotid artery, because the second sound can be 
heard here when absent at the aortic cartilage; 
when the second sound is audible over the carotid, 
it indicates the regurgitation is small in amount, 
and hence a favorable prognostic element. 



VALVULAR DISEASE OF THE HEART. 137 

Remember that the murmur heard has a soft, 
blowing quality, and is loudest at midsternum, oppo- 
site the third costal cartilage, or along the left bor- 
der of the sternum. It is heard during ventricular 
diastole, and is produced by back-flow of blood from 
the aorta. 

The Austin Flint murmur is a second murmur 
limited to the apex, and is of a "rumbling, echoing' ' 
character. It is presystolic in time and occurs in 
the latter half of diastole. It is often associated 
with a palpable thrill. 

Remember that this is the lesion associated with 
massive hypertrophy, and the apex beat may be 
seen in the seventh or eighth interspace on the 
anterior axillary line. 

Aortic Stenosis. 

Remember that arterial changes, which are so 
prone to occur in old men, lay the foundation for 
stenosis. 

Remember that no symptoms appear until a break 
in compensation occurs, when the earliest are those 
of cerebral anemia — viz., syncope, dizziness, head- 
ache. 

Remember that, while the high degree of muscu- 
lar hypertrophy is present, yet the apex beat may 
not be easily seen because of coexisting pulmonary 
emphysema. 

Remember that a marked, systolic thrill, most in- 
tense in the aortic region, is very characteristic of 
this lesion. 



138 DISEASES OF THE VASCULAK SYSTEM. 

Remember that the murmur is a harsh systolic, 
and loudest over the second right costal cartilage. 

Remember that the murmur is transmitted into 
the carotids, and it often has a musical quality. 

Remember that not every murmur heard in this 
region is due to aortic stenosis. Calcareous plates 
in the aorta or on the cusp produce a very similar 
sound. Anemia causes hemic murmurs that are 
often best heard in the aortic area, but this soft 
bruit is very different from the loud, harsh murmur 
of stenosis. 

Remember that in both the sclerosis and the 
anemia the aortic second sound is heard, and in the 
former it is accentuated. 

Remember that the pulse is small and slow — 
pulsus tardus — and is somewhat characteristic of 
stenosis. 

Mitral Incompetency. 

Remember that so long as muscular hypertrophy 
is able to overcome the valvular defect, the patient 
will suffer no inconvenience from the lesion, except 
perhaps a little shortness of breath on sudden ex- 
ertion, as running up a flight of stairs. 

Symptoms are not a sign of the beginning of the 
lesion, but of the beginning of inequality between 
the lesion and the hypertrophy. 

Remember that this is the lesion which, in long- 
standing cases, particularly in children, produces 
clubbing of the fingers. 



VALVULAR DISEASE OF THE HEART. 139 

Remember that attacks of bronchitis and hemo- 
ptysis are quite frequent, due to the pulmonic con- 
gestion. 

Remember that we have persistent cough, with 
blood-stained sputa, containing alveolar cells and 
pigment granules. 

Remember that the cardiac ' ' sleep start ' ' is a dis- 
tressing symptom. Just as the patient falls asleep 
he wakes, gasping for breath and feeling as though 
the heart were stopping. 

Remember the peculiarity of the pulse. It is ir- 
regular, with no two beats of equal force or volume, 
and persists even though compensation be re-estab- 
lished. 

Remember that the apex beat will be found dis- 
placed downward and to the left, and is seen in the 
sixth costal space to the left of the nipple line. 

Remember that the murmur is systolic, and loud- 
est at the apex. It is a blowing sound, and may 
entirely replace the valvular sound. 

Remember that this murmur may be heard also 
in the axillary space and beneath the angle of the 
scapula posteriorly. 

Remember the peculiar phenomenon that the re- 
cumbent position makes it plainer, and often a mur- 
mur can be heard in the recumbent posture that is 
inaudible in the upright position. 

Remember that percussion shows decided lateral 
increase of the heart, due to hypertrophy. 

Remember that the three important physical 
signs of mitral regurgitation are : 



140 DISEASES OF THE VASCULAR SYSTEM. 

1. A systolic murmur, loudest at the apex and 
propagated to the axilla and heard at the angle of 
the scapula. 

2. Accentuation of the second pulmonic sound. 

3. Increase in the transverse diameter of cardiac 
dullness, due to hypertrophy of both ventricles. 

Mitral Stenosis. 

Remember that this is much more common in 
females. 

Remember that this is the only valvular lesion 
that has a characteristic thrill on palpation. 

Remember that the hypertrophy is all in the right 
heart and increase of dullness is to right of sternum. 

Remember that the thrill is felt best in the 
fourth or fifth space within the nipple line, limited 
in area and best felt during expiration. It is rough, 
grating in quality, and can be felt to terminate in 
a sharp, sudden shock, synchronous with the im- 
pulse. 

Remember that the enlarged auricle may press 
upon the left recurrent laryngeal nerve, and cause 
paralysis of the vocal cords on the same side. 

Remember that the murmur is heard to the inner 
side of apex beat or along the left sternal border, 
and sometimes can be heard only when the breath 
is held. It is a rough, vibratory, or purring sound, 
and gradually becomes louder until it terminates in 
the first sound. This murmur is synchronous with 
the thrill felt on palpation. 



VALVULAR DISEASE OF THE HEART. 141 

Tricuspid Insufficiency. 

Remember that the signs are those of retarded 
pulmonary circulation and visceral congestion. 

Remember that the pnlse wave is seen in the veins 
of the neck, more pronounced in the right jugular. 

Remember that often an expansile pulsation of 
the liver may be palpated. This may best be de- 
tected by bimanual palpation. One hand is placed 
over the fifth and sixth costal cartilages, the other 
over the lower border of the liver in the midaxillary 
line, when a rhythmical expansile pulsation may be 
felt. 

Remember that a low systolic murmur is heard 
best over the lower part of the sternum and propa- 
gated in the direction of the right axilla. 

Crural Vein Sound. A valve sound may be heard 
over the crural vein, either single or double. If 
double, it corresponds to the presystolic and systolic 
filling of the vein. 

Tricuspid Stenosis. 

Remember that this condition is almost invariably 
associated with tricuspid insufficiency. 

Remember that there is a presystolic murmur, 
best heard at the base of the ensiform cartilage. 

Remember that this murmur is associated with 
a presystolic thrill. Cardiac dullness is increased 
toward the right. 

Remember that cyanosis of the face and lips is. 
commonly seen, and becomes pronounced where 
dropsy occurs. 



142 diseases of the vasculak system. 

Treatment of Valvular Lesions. 

Remember that a heart with a lesion does not need 
treatment so long as hypertrophy overcomes the ill 
effects of the lesion. There is as much wisdom in 
knowing when not to treat cardiac lesions as there 
is in knowing what to do when active treatment is 
called for; hence we may divide the treatment into 
stage of compensation and stage of broken compen- 
sation. 

Stage of Compensation. 

In this stage the treatment is wholly dietetic and 
mechanical. 

Diet. The food should be abundant and nutri- 
tious. Coffee may be allowed, especially in the 
elderly. Milk should form a good part of the diet, 
but meats of all kinds are allowable in moderation. 
Fruits of various kinds and vegetables, especially 
spinach, lettuce, carrots, cauliflower. 

The digestive tract must be watched, that gases 
do not form in the stomach and interfere with 
cardiac action. 

Cathartics should occasionally be used, and sa- 
lines are best, unless the patient is greatly weak- 
ened. 

Fluids must be allowed in moderation. It is bet- 
ter if the patient takes less than the ordinary 
amount in health. More should be allowed in hot 
weather. 



VALVULAR DISEASE OF THE HEART. 143 

Tobacco is allowable in old smokers, as it will 
have no injurious effects; otherwise it is best to 
forbid it. 

Salt should be eliminated as much as possible 
from the food. It should be rigidly withdrawn 
when dropsy appears. 

Rest after eating should always be insisted upon, 
the length of time depending upon the individual 
case. 

Exercise should be moderate and in the open air. 
Violent or long-exhausting undertakings must be 
prohibited. Worry and anxiety are never allowable, 
and the patient must lead a quiet, even life. 

Baths. The skin should be kept active and free 
by tepid baths or sponging. Hot or cold baths 
should not be used. Turkish baths must be pro- 
hibited. 

Clothing. Flannel next to the skin is best, but 
care not to dress the patient too warm is just as 
important. The skin must be protected from sud- 
den chilling, as this causes visceral congestion and 
increases cardiac work. 

Medication is indicated only as designed to tone 
up the whole system. For anemia and as a general 
tonic and a stomachic, arsenic is excellent. Fow- 
ler's solution may be given, or combined as follows: 

I£ Liquoris potassii arsenitis, 

Tincturse Valerianae aa 3 ij 

Misce. 

Sig. : 4 drops in water three times daily. Increase 1 
drop per day until 8 drops are taken. 



144 DISEASES OF THE VASCULAR SYSTEM. 

Or: 

B Arseni trioxidi gr. iss 

Piperis . gr. xv 

Acacias gr. iij 

Aquae q. s. 

Misce et fiant pilulae No. XX. 

Sig. : Pill three times daily. 

Quinin as a tonic may be used, but it is not so 
good. 

P* Tincturas cinchonas composite %iv 

Sig.: Teaspoonful in water three times daily before meals. 

Or: 

Ifc Tincturse cinchonas composites, 

Tincturas gentianas compositas . . aa £ ij 
Misce. 
Sig.: Teaspoonful three times daily before meals. 

Stage of Broken Compensation. 

Rest should be complete. The patient should be 
confined to his bed. 

Diet. So long as digestion is good or hydrops is 
not present the diet should be liberal. When either 
condition appears, the diet must be restricted. Best 
— milk, two pints, and add well-cooked cereals, 
shredded wheat biscuits, zwieback, toasted bread, 
and unsalted butter. Later soft egg, chicken, quail, 
lamb, or veal chops, and potatoes. 

Cold, locally — either the ice bag, Leiter's coil, or 
cold compress — should be laid over the cardiac re- 
gion. The compress should be changed as soon as 
it gets the least warm. 

Cardiac Stimulants. The best is digitalis. It 



VALVULAR DISEASE OF THE HEART. 145 

slows the rate and strengthens the beat. Don't for- 
get its cumulative action. The effect on the heart 
can be detected as long as nine days after its use. 
There are various forms and preparations in which 
it may be given. 

R Infusi digitalis ( fresh leaves ) . . . . 5 iv 
Sig. : Tablespoonful every two or three hours. 

Or: 

B Tincturas digitalis, 

Tincturas scillae aa, 3 iv 

Misee. 

Sig.: 20 to 30 drops three times daily. 

Or: 

I£ Digitaloni Til xv 

Sig. : May be given every four hours hypodermatieally. 

Or: 

I£ Digitalini gr. ss 

Alcoholis TT\, xv 

Aquse 3 i j 

Mi see. 

Sig.: Inject 10 to 20 minims subcutaneously. 

Or: 

1$. Potassii acetatis gr. xx 

Tincturse digitalis TTt xv 

Tincturas scillae Tl\ xl 

Tincturas nucis vomicae TTt v 

Infusi senegas q. s. ad 3 j 

Misce et fiat haustus. 

Sig. : To be taken every four hours. 

Or: 

I£ Tincturas scillae 3 iv 

Tincturas digitalis 3 iij 

Aquas cassias q. s. ad g vj 

Misce. 

Sig.: Tablespoonful every four hours. 



146 DISEASES OF THE VASCULAR SYSTEM. 

Remember that there are some conditions that 
contraindieate digitalis, or that require the drug to 
be administered very cautiously or in combination 
with other drugs. In a diseased heart muscle, es- 
pecially in aortic incompetency, it should be given 
cautiously, and, no improvement following, it should 
be abandoned. 

Fatty degeneration of the cardiac muscle and an 
extensive myocarditis contraindieate digitalis. In 
an abnormally slow heart, to be determined by 
cardiac auscultation and not by the radial pulse, 
digitalis should be combined with a tropin (Ortner), 
thus: 

B Atropini sulphatis gr. % S T - Veo 

Syrupi rubi idaei 3 iv 

Infusi digitalis q. s. ad § vj 

Misee. 

Sig. : Tablespoonful every two or three hours. 

In cases of extensive arteriosclerosis, digitalis is 
dangerous, unless the peripheral constriction is 
counteracted. Nitroglycerin should be combined 
with it, thus: 

B Tincturae digitalis, 

Tincturae nucis vomicae aa 3 i j 

Spiritus glonoini T1X xij 

Tincturae cardamomi comp. q. s. ad % iij 

Misce. 

Sig. : Dessertspoonful every three or four hours. 

Two other drugs are of value, either when digi- 
talis can not be used or to supplement its action. 
They are strophantus and spartein. 



VALVULAR DISEASE OF THE HEART. 147 

Strophanthus may be given alone, 10 to 15 drops 
of the tincture, or as: 

R Tincturse strophanti, 

Tincturse Valerianae aa 3 i j 

Misce. 

Sig. : 10 to 30 drops three times daily. 

Spartein may be exhibited in solution, powder, or 
pills, as: 

Ifc Sparteine sulphatis gr. iv 

Syrupi aurantii g vj 

Misce. 

Sig.: Tablespoonful three or four times daily. 

Or: 

B Sparteine sulphatis gr. vj 

Glycyrrhizae q. s. 

Misce et fiant pilulse No. XX. 

Sig. : Pill three or four times daily. 

With sign of cardiac failure — pulse hardly palpa- 
ble, heart tones weak, and the extremities cold and 
livid — camphor should be given hypodermatically. 

B Camphorae 3 ss 

Olei olivse 3 ij 

Misce et fiat solutio. 

Sig.: Inject 5 minims as necessary. 

Venesection is life-saving when dilatation occurs. 
When signs of venous engorgement occur, and when 
there is orthopnea with cyanosis, the withdrawing 
of from 20 to 30 ounces of blood is urgently indi- 
cated. 

Dropsy is frequently relieved by rest and a course 
of digitalis, but at times it is necessary to resort to 
other measures. 

Diuretics are then indicated. 



148 DISEASES OF THE VASCULAR SYSTEM. 

Diuretin, which is sodium salicylate of theobro- 
min, has the advantage of stimulating the renal 
epithelium without injury. It is insoluble in cold 
water and is best given in powder, as: 

R Diuretini gr. x 

Fiat pulvere No. I. Dentur tales doses Xo. XXV. 
Sig. : Powder every three hours. 

Or it may be given in solution, as diuretin is 
soluble in hot water, as: 

3 Diuretini 3 j-3 iss 

Essentia? pepsini (Fairchild) § ij 

Aqua? 5 v 

Dissolve diuretin by slightly heating water. 

Misce et fiat solutio. 

Sig. : Tablespoonful every two hours. 

Theocin-sodium acetate gr. iij-gr. v four to six 
times daily, and should not be given on an empty 
stomach. 

Calomel in many cases produces marked diuresis. 
The effect usually begins three or four days after 
beginning treatment and continues four or five days 
after treatment stops. It should be given only for 
three or four days and then stopped for an equal 
length of time. When it causes diarrhea, this may 
be overcome by giving gtt. iij-gtt. v of deodorized 
tincture of opium with it. Hydrogen peroxid should 
be used as wash for the mouth during the adminis- 
tration. 

3 Hydrargyri chloridi mitis gr. iij 

Sacchari lactis gr. vj 

Misce et fiat pulvere No. I. Dentur tales doses No. X-XII. 
Sig.: Powder three times daily. 



VALVULAR DISEASE OF THE HEART. 149 

If the pulse is weak, it is better to administer digi- 
talis three or four days before giving the calomel. 
Addison's or Niemeyer's pills are excellent, as they 
are a combination of digitalis, calomel, and squills 
aa gr. j. One pill should be given three or four 
times a day for four or five days. Care should be 
used because of salivation if continued for too long 
a time. 

. Cathartics may be used to remove dropsy, and 
of these concentrated solutions of the salines are 
best. Strong purges, like colocynth, should be 
avoided. 

Multiple incisions or paracentesis is at times 
necessary to get rid of the dropsy, and should be 
resorted to when other measures fail. 

Insomnia. A cup of hot gruel at bedtime, a tepid 
bath, or a light evening meal will be all that is neces- 
sary in many instances. Sodium bromid may be 
used. 

I£ Sodii broraidi 3 ij 

Syrupi rubi idsei % iss 

Aquse q. s. ad § iv 

Misce. 

Sig. : Tablespoonful in evening and repeat in hour if 
necessary. 

If salt is withheld from the food, better effect of 
the bromid will be obtained, as salt hastens elimi- 
nation; a good point, also, to remember in cases of 
bromism. 

Bromipin in from 2 to 4-dram doses in the after- 
noon and evening often acts better than bromids. 



150 DISEASES OF THE VASCULAR SYSTEM. 

Veronal is a good, safe hypnotic. Best given in 
glass of milk. It may be given in 5-grain doses and 
repeated in one to two hours. 

Cough is almost always present. When it be- 
comes annoying, codein gr. % should be given. An 
excellent combination is a tablet put up by Abbott, 
of Chicago, and has the following formula: 

I£ Zinci sulphocarbolatis gr. j 

Codeini sulphatis gr. % 

Hyoscyaminae hydrobromatis gr. i^5 

Strychninse sulphatis gr. 1^34 

Misce et fiat tabella Xo. I. 

Sig. : Tablet every one or two hours. 

Tlie Schott Movements. 

The Schott or Nauheim system of treatment of 
cardiac affections consists in the proper resistance 
exercise. The exercise is such that different groups 
of muscles work against a gentle resistance of the 
physician or attendant. Careful watch must be kept 
during the movements, and on any sign of circula- 
tory or respiratory trouble the movements are at 
once suspended. 

The following are some of the movements used, 
each exercise being made against slight resistance 
applied by the physician: 

1. The arms are extended in front of the body at 
the level of the shoulder, with the palms touching. 
The arms are then moved slowly outward until they 
are in a line with each other, and are then brought 
forward to the original position. 



VALVULAR DISEASE OF THE HEART. 151 

2. The arms and hands hang at the side, with 
the palms forward. The forearm is flexed upon the 
arm until the fingers touch the shoulder. The fore- 
arm is then extended to its original position. This 
exercise is first done with one arm and then with 
the other. 

3. The arms and hands in position as in No. 2. 
The arms are raised until the thumbs meet over the 
head and then return to original position. 

4. Same as No. 3, except fingers are flexed at 
first phalangeal joint. 

5. Arms, hanging in position of " attention, ' 9 are 
brought forward parallel to each other until they 
are elevated to a vertical position, and then re- 
turned to original. 

6. Same as No. 1, except with fists clenched. 

7. Same as No. 2, except with fists clenched. 

8. The arms, starting from the position of " atten- 
tion,' ' describe a circle by moving forward and up- 
ward until they are raised vertically; then each 
palm is turned outward and the arms descend back- 
ward to their original position. 

9. The body is bent forward and then brought 
back to the erect position, the knees not being 
moved. 

10. The body is rotated first to the right and then 
to the left without any movement of the feet. 

11. The body is flexed first to the right and then 
to the left as far as possible without moving the 
feet. 



152 DISEASES OF THE VASCULAR SYSTEM. 

12. The patient in the erect posture, feet close to- 
gether, and one hand resting on a support, the oppo- 
site thigh is flexed as far as possible, then extended, 
and foot brought into its original position. The 
other hand is placed on a support and the opposite 
thigh is flexed the same as the other. 

Palpitation. 

Remember that this is more frequently found in 
women, and hysteria is often the causative factor. 

Eemember that dyspepsia, especially if associ- 
ated with neurasthenia, is often the cause. 

Remember that the symptoms vary from a mild 
form, as seen in dyspeptic attacks, when there is 
slight fluttering of the heart, to the severe forms, 
when cardiac action is violent and the arteries 
throb forcibly. 

Remember that the pulse rate may be high — 
150 to 160 — with diffuse flushing of the skin. A 
large quantity of pale urine may be passed after 
such an attack. 

Remember that the presence of a diastolic mur- 
mur excludes nervous palpitation. 

Remember that the area of cardiac dullness is 
not enlarged, thus excluding hypertrophy. 

Remember that the fact of intervals between at- 
tacks, when the patient is free of palpitation, is 
strongly suggestive of neurosis. 

Remember that if the patient is anemic, murmurs 
will be heard — systolic, soft, blowing — but the valve 



PALPITATION. 153 

sounds will be normal and there will be no hyper- 
trophy of the heart. 

Treatment. 

First, quiet the patient's fears by assuring him 
that there is no actual danger. Second, seek out 
the cause, and inaugurate the proper hygienic and 
dietetic regimen. 

Eegular hours should be kept, and ten hours of 
sleep insisted upon. Tepid bath, at night if nervous, 
or in the morning on arising. The evening meal 
must be light — mainly soups. 

Sexual excitement is particularly prone to keep 
up the trouble and patients should be specially 
warned. A Weir-Mitchell course of treatment is 
best where neurasthenia is the causative factor in 
women. Anemia demands iron. The following 
formulas are good: 

I£ Ferri et quininae citratis gr. xl-gr. lx 

Liquoris strychnines ITj, xl 

Spiritus chloroformi 3 i j 

Acidi hydrobromici TTt lxx 

Aquae q. s. ad % iv 

Misce. 

Sig. : Tablespoonful three times a day before meals. 



Or: 



J> Ferri et ammonii citratis gr. lxx 

Tinctures nucis vomicae 3 iss 

Sodii bromidi 9 iv 

Spiritus ammonii aromatici 3 iv 

Aquae q. s. ad g iv 

Misce. 

Sig.: Tablespoonful three times daily. 



154 DISEASES OF THE VASCULAR SYSTEM. 

When gastric disturbances are the cause, as seen 
in distention of the stomach by gas formed by the 
decomposition of food, medication directed toward 
the prevention of the gas formation is indicated. 

B Bismuthi carbonatis gr. x 

Magnesii carbonatis gr. v 

Sodii bicarbonatis gr. x 

Aquse laurocerasi 3 j 

Aquas caryophilli q. s. ad § j 

Misce et fiat haustus. 
Sig. : To be taken two times a day an hour before meals. (Yeo.) 

Or: 

I£ Phenolis gr. xv 

Glycerini 3 v 

Bismuthi carbonatis 3 iiss 

Lactis magnesii q. s. ad 5 iv 

Misce. 

Sig. : Two teaspoonfuls after meals. 

Aconite or veratrum viride may be nsed where 
there is great rapidity of cardiac action. 

Digitalis is seldom indicated, but in obstinate 
cases it may be given in combination with nux 
vomica. 

Remember that strychnin, in the form of tincture 
of nux vomica, and given in large doses, 20 drops 
three times daily, gives the best results in most 
cases. 

Angina Pectoris. 

Remember that this condition occurs almost ex- 
clusively in men, and, when occurring under thirty- 
five, syphilitic aortitis is an important factor. 



ANGINA PECTORIS. 155 

Remember that gout and diabetes are important 
etiologic factors, and angina pectoris has been 
known to follow influenza. 

Remember that arteriosclerosis is present in 
practically all the cases, but the degree of sclerosis 
of the palpable arteries is no criterion of the degree 
of degeneration of the coronary vessels. 

Remember that in angina an attack is usually 
caused by sudden exertion, mental worry, exposure 
to cold, or a hearty meal. 

Remember that the onset is sudden and usually 
without any warning. 

Remember the three essential phenomena: 

1. Pain, agonizing, felt in the precordium and be- 
neath the manubrium. The pain radiates to the 
neck and into the left arm along the distribution of 
the ulnar nerve. 

2. The sense of constriction of the heart — feeling 
as though the heart were being " grasped by a 
mailed hand." 

3. The sense of impending death. The face is 
pallid, gray, and bathed in sweat. 

Remember that death may occur during an at- 
tack. 

Remember that paroxysms may occur frequently 
or at long intervals of time 

Remember that there is a neurotic form that close- 
ly simulates true angina. 

Remember that the neurotic form occurs more fre- 
quently in women — periodically; that the attack 



156 DISEASES OF THE VASCULAR SYSTEM. 

lasts one or two hours, during which there is agita- 
tion and activity, associated with nervous symp- 
toms, and is never fatal. 

Treatment. 

During an Attack. 

Nitrite of amyl by inhalation frequently gives re- 
lief; from 3 to 5 minims on handkerchief or sponge 
may be inhaled. Patient should carry the "pearls," 
and be instructed to break one and inhale from 
handkerchief on first signs of an attack. 

Chloroform inhalation should be resorted to if 
amyl nitrite inhalations do not give relief. Usually 
this is the most effective way, and it is free of 
danger. 

Morphin hypodermatically may be used, but bear 
in mind that it requires a large dose to give relief. 
Give at least gr. /4-gr. ss combined with atropin 
sulphate gr. y 100 . 

Interval Treatment. 

Patients should live a quiet life, free from worry 
and excitement. Muscular exertion must not be 
sudden or prolonged. 

Substances that, in the course of time, have a 
toxic action on the heart must be avoided, as these 
substances may be the cause of severe attacks of 
angina. This is particularly true of tobacco, and 
the peculiar thing about it is that the patient may 
use tobacco for years without any apparent ill effect 



ANGINA PECTOKIS. 157 

until, arriving at midlife, it begins to manifest 
its toxic action. Tea and coffee are likewise harm- 
ful, and should be excluded. 

Elimination is exceedingly important in the 
treatment. Toxic substances absorbed from the 
bowels are, without doubt, potent factors in caus- 
ing high blood pressure and vascular sclerosis. 
Many of the cases give a history of dyspepsia of 
long duration. 

Diet is, therefore, important, and should be light 
and nutritious. An exclusive milk diet for a while 
is excellent. Cream should be added to the milk. 
Fresh vegetables and fruits are indicated. Eggs, 
butter, and the lean of fresh meat minced and 
lightly cooked may be allowed. 

Regular evacuation of bowels is very essential, 
because it will check the formation of injurious sub- 
stances. Aperient waters or salines may be used. 
An excellent dinner pill may be exhibited as follows: 

IJ Extracti aloes, 

Pulveris ipecacuanha^ 

Pulveris nucis vomica?, 

Saponis aa gr. j 

Misce et fiat pilula No. I. Dentur tales No. XXV. 
Sig. : Pill morning and evening. 

Nitroglycerin should be given for its relaxing 
action upon the blood vessels; it may be given in 
doses of gr. % o and gradually increase until effect. 

Spirits of glonoin may be used, which represents 
M.00 grain of nitroglycerin to the minim. Begin 
with 1 minim three times daily and increase 1 minim 



158 DISEASES OF THE VASCULAR SYSTEM. 

every fifth day until the patient complains of flush- 
ing or headache. 

Iodids, either the potassium or sodium, admin- 
istered for one or two years, stopping ten days in 
each month, are excellent. 

P£ Sodii iodidi 3 iiss 

Sodii arsenatis gr. % 

Aquse destillatae q. s. ad g v 

Misce. 

Sig.: Teaspoonful three times daily. 

Or: 

I£ Tincturse digitalis 3 j 

Tincturse strophanti 3 j 

Spiritus glonoini ( 1 -percent) TTL xxiv 

Tincturse cardamomi q. s. ad § iij 

Misce. 

Sig.: Teaspoonful three times daily. 

Or: 

I£ Potassii iodidi, 

Aquse aa 3 j 

Sig. : 20 drops three times daily, stopping for a week in 
each month, but continuing the treatment for a couple of 
years. 

Water should be drunk liberally, unless the kid- 
neys are so affected that elimination is interfered 
with. 

Arteriosclerosis. 

Remember that the history of the patient gone 
into carefully often reveals the cause. Syphilis, 
gout, arthritis, and heredity are the chief causes. 

Remember that this is a change common to old 
age, and is similar to the sclerotic changes of other 
tissues. 



AETERIOSCLEROSIS. 159 

Remember that the two classes of men most 
likely to develop it are the laborer who does heavy, 
muscular work, and the brain worker who is sub- 
ject to a great amount of worry. 

Remember that high blood pressure, a palpable 
thickening of the arteries, hypertrophy of the left 
ventricle of the heart, and the accentuation of the 
aortic second sound are pathognomonic of arterio- 
sclerosis. 

Remember that there are renal symptoms in some 
of the cases — viz. : increased amount of urine, tran- 
sient albuminuria, and few hyaline tube casts. 

Remember that in some cases the cardiac hyper- 
trophy is followed by dilatation, and a murmur can 
be heard at the apex. 

Remember that when the hypertrophy fails to 
compensate for the arterial resistance, there will be 
dyspnea, vertigo, and chronic bronchitis. 

Remember that the subsequent symptoms depend 
upon the location of* the sclerosis in the vascular 
area. 

Remember that sclerosis of the coronary arteries 
may lead to thrombosis and sudden death, or aneu- 
rism of the heart, or angina pectoris. 

Remember that if the cerebral vessels are the seat 
of extensive sclerosis, we may have transient hemi- 
plegia, monoplegia, or aphasia. 

Remember that these attacks are transient, last- 
ing usually less than twenty-four hours, with perfect 
recovery, and may be followed later by a recurrence. 



160 DISEASES OF THE VASCULAR SYSTEM. 

Eemember that vertigo, slow pulse, and epilepti- 
form attacks may occur. 

Eemember that intermittent claudication is very 
common. It is an intermittent lameness caused by 
muscular activity of certain groups of muscles of the 
limbs, followed by cramps. 

Treatment. 

Early diagnosis is necessary if anything of per- 
manent value in treatment is to be done. 

Diet should consist largely of milk and its prod- 
ucts, with vegetables and fruits. Meat should be 
reduced to the minimum. 

A quiet life, free from worry, and moderate open 
air exercise is indicated. 

Baths of room temperature or sponging is excel- 
lent. Massage of the abdomen and extremities, if 
long continued, will lower the blood pressure. 

The bowels should be kept open by vegetable or 
saline cathartics. 

The kidneys must be kept active. For this pur- 
pose theobromin is useful. 

B Theobromini gr. x 

Fiat dosis Xo. I. Dentur tales doses Xo. XXX. Dispense 
in gelatin capsules. 

Sig. : Capsule four to six times daily. 

Other diuretics, described under heart disease, 
may be used if necessary. 

lodids and arsenic are the two drugs that give 
best results. 



ARTERIOSCLEROSIS. 161 

R Potassii or sodii iodidi 3 i j vel 3 iv 

Sodii bicarbonatis gr. lxxv 

Aquae nienthae piperita^ 

Aquae destillatae aa % iiss 

Misce et fiat solutio. 

Sig. : Tablespoonful after meals. 

Vierordt advises 2 or 3 grains of sodium iodid 
three times daily and gradually increase the dose 
until 15 grains three times daily are taken. This is 
kept up for from one to three years, omitting the 
treatment one week in five. 

Calomel purge, frequently given, will greatly aid 
in the plan of treatment. 

With a feeble heart the following combination is 
good : 

R Sodii iodidi 3 j 

Sparteinae sulphatis gr. xv 

Pulveris glycyrrhizae q. s. 

Misce et fiant pilulae No. XL. 

Sig. : Pill after meals. 

Arsenic may be exhibited as Fowler's solution, or 
as in the following: 

IJ Arseni trioxidi gr. ss 

Ferri reducti gr. xxx 

Euquinini ( Merck ) 3 j 

Extracti rhamni purshianae 3 iss 

Misce et fiant pilulae No. XXX. 

Sig.: Pill after each meal. 



Or: 



Ifc Potassii iodidi 9 iv 

Ammonii chloridi 3 j 

Syrupi sarsaparillae compositae .... 5 j 
Aquae destillatae q. s. ad % ij 

Misce. 

Sig.: Teaspoonful in milk after meals. 



162 DISEASES OF THE VASCULAR SYSTEM. 

If cardiac insufficiency manifests itself, tonics are 
indicated, and of these perhaps tincture of digitalis 
in 10-minim doses, combined with 1 minim of spirits 
of glonoin, three times daily, or oftener if the symp- 
toms are urgent. 

Venesection, with abstraction of 20 ounces of 
blood, gives immediate relief in cases of engorge- 
ment. The amount of blood withdrawn should not 
be replaced with the saline solution, as it is the re- 
duction of the circulating liquid that is desired. 



CHAPTER X. 

DISEASES OF THE LUNGS AND PLEURA. 

Acute Bronchitis. 

Remember that in typhoid and malaria it is an 
early symptom. 

Remember that influenza, measles, and whooping- 
cough are accompanied by acute bronchitis. 

Remember that substernal soreness and in the 
region of the attachment of the diaphragm is com- 
mon, and is due to cough. 

Remember that fever is frequently present, and 
may reach 102° or 103° F., but usually lasts only a 
few days. 

Remember that cough is " tight" in early part of 
attack, due to tenacious, scanty mucus adhering to 
swollen mucosa of the tubes. 

Remember that sibilant or sonorous rales are 
heard during this period of dry cough. 

Remember that the larger the bronchi affected, 
the less are generally the signs caused by the bron- 
chitis. 

Remember that the percussion sound over the 
thorax is never altered by uncomplicated bronchitis. 

Remember that blowing sounds are never heard 
in bronchitis, but that the vesicular murmur is 
heard, and the only alteration is that it is sharp and 
loud (puerile), and there is prolonged expiration. 

163 



164 DISEASES OF THE LUtfGS AXD PLEUE^. 

Remember that mucous, bubbling rales appear 
when the cough loosens. Bronchial fremitus may 
be felt on palpation. 

Remember that cyanosis and increased respira- 
tory rate in dyspnea that are not relieved by the 
cough indicate the process has involved the small 
tubes — capillary bronchitis. 

Remember that the epigastrium and hypochon- 
driac region are retracted during inspiration in capil- 
lary bronchitis, in contradistinction to the normal 
inspiratory bulging. 

Remember that the percussion sound is not al- 
tered. If dull areas are found, it signifies bronchi- 
pneumonia or atelectasis. Therefore examine such 
a chest daily for this important change in percus- 
sion. 

Remember that bronchial breathing heard on aus- 
cultation is never present in any form of bronchitis. 

Remember that spirals are found in the sputum 
in capillary bronchitis; also Charcot's crystals. 

Treatment. 

In mild cases, hot foot bath, a mustard plaster to 
the chest, applied over the sternum and extending 
out to nipple line on either side. The plaster should 
not remain on long enough to blister. A glass of hot 
lemonade at bedtime will suffice in mild cases. For 
the severer forms a hot bath at night on going to 
bed. When Turkish baths are taken, one must go 
directly from the bath to bed, because any exposure 
after such a bath is exceedingly dangerous. 



ACUTE BRONCHITIS. 165 

Bowels should be moved freely by saline. 

The atmosphere of the room should be moist. This 
may be done by steam from boiling water. This is 
better if salt (NCI) and soda are added to it. 

The cough may be relieved by opium, or, better, 
codein. In the dry stage the secretion of mucus 
must be stimulated. 

R; Codeinae phosphatis gr. v-gr. vii j 

Liquoris ammonii acetatis 3 iv 

Syrupi ipecacuanhae 3 i j 

Syrupi pruni virginianae 3 iv 

Aquae q. s. ad 5 iv 

Misce et fiat solutio. 

Sig. : Teaspoonful every two hours. 

Or: 

R: Ammonii carbonatis 3 ij 

Ammonii iodidi 5 ii j 

Syrupi glycyrrhizae ^ ij 

Syrupi tolutani § i j 

Misce et fiat solutio. 

Sig.: Teaspoonful every two or three hours in water. 

The above combinations are particularly useful in 
capillary bronchitis. 

IJ. Ammonii chloridi, 

Sodii salicylatis aa 3 ij 

Tincturae hyoscyaminae 3 v j 

Misturae glycyrrhizae comp. q. s. ad % iij 
Misce. 
Sig.: Teaspoonful every three hours. 

Or: 

IJ Codeinae phosphatis gr. iv 

Ammonii carbonatis gr. xxx 

Tincturae hyoscyaminae 3 iv 

Syrupi pruni virginianae 3 vj 

Aquae camphorae q. s. ad g ij 

Misce. 

Sig.: Teaspoonful every two hours. 



166 DISEASES OE THE LUNGS AND PLEURAE. 

Or: 

B Vini antimonialis 3 ij 

Spiritus aetheris nitrosi 3 iv 

Liquoris ammonii acetatis 5 ij 

Tincturae camphorae composite . . . . 3 i j 

Aquae q. s. ad 3 iv 

Misce. 

Sig. : Tablespoonful every three or four hours. To be 
used with tense pulse, fever, and dry, hot skin. 

With the establishment of secretion, the medica- 
tion shonld be changed. This is now the time for 
squills and senega, but they are contraindicated 
until this stage is reached. 

B Inf usi senegae 5 iv 

Ammonii carbonatis gr. xxxij 

Tincturae scillae 3 iiss 

Spiritus chloroformi 3 ij 

Aquae q. s. ad § viij 

Misce et fiat misturae. 

Sig.: 2 tablespoonfuls every four hours. 

Or: 

B Tincturae veratri viridi TTL xx 

Vini antimonialis 3 iv 

Tincturae opii camphoratae 3 iiss 

Liquoris ammonii acetatis 5 ij 

Misce. 

Sig. : Teaspoonful in little water every two, three, or four 
hours. 



Or: 



Ifc Camphorae gr. j 

Extracti belladonnae gr. %-gr. 14 

Quininae sulphatis gr. ij 

Pulveris ipecacuanhae et opii gr. j 

Misce et fiat capsula No. I. Dentur tales No. XV. 

Sig.: Capsule hourly for four doses, then every three hours. 



ACUTE BRONCHITIS CHRONIC BRONCHITIS. 167 



Or: 

B Ammonii chloridi 3 j 

Terpini hydratis 3 j 

Pulveris ipecacuanhas et opii gr. xxiv 

Misce et fiant capsulae No. XXIV. 

Sig.: 1 or 2 capsules, according to age, every three hours. 

Or: 

IJ Ammonii chloridi 3 ij 

Potassii iodidi gr. xv 

Tincturae ipecacuanhae TTj. xxx 

Misturae glycyrrhizae comp. q. s. ad 3 iv 

Misce. 

Sig.: Tablespoonful every four hours during dry stage. 

Or: 

B Syrupi ipecacuanhas 3 iv 

Ammonii chloridi © iv 

Tincturae opii camphoratae 3 ij — 3 iij 

Syrupi tolutani q. s. ad % i j 

Misce. 

Sig. : Teaspoonful every two hours as a sedative expectorant. 

Aconite may be used for reduction of fever. It 
should not be used in old people or in cases where 
the heart is weak. 

Diet should be light. Liquid for a few days is 
best. Tonics may be needed during convalescence, 
and there is nothing better than elixir of iron, 
quinin, and strychnin, a teaspoonful after meals. 

Chronic Bronchitis. 

Remember that this is often secondary to other 
conditions, as emphysema, heart disease, typhoid 
fever, and phthisis. 

Remember that occupation is a very important 



168 DISEASES OF THE LUNGS AND PLEUKJE. 

factor in its causation — such occupations where 
gases or dust are inhaled. 

Remember that it is common in the gouty condi- 
tions, often spoken of as uric acidemia. 

Remember that this is a disease of the aged and 
is the well-known "winter's cough" of old men. 

Remember that there are two forms — viz., dry 
and moist, the latter also known as bronchorrhea. 

Remember that the dry is characterized by severe 
fits of coughing, with very little secretion brought 
up. 

Remember that shortness of breath on exertion, 
so common in these cases, is due to an associated 
emphysema or cardiac weakness. 

Remember that the sputum is usually purulent 
or mucopurulent, and generally abundant. 

Remember that inspection shows a distended 
chest with limited movement, due to coexisting em- 
physema. 

Always examine the heart and urine in all cases 
of chronic bronchitis to determine whether the bron- 
chitis is primary or secondary. 

Remember that in pulmonary tuberculosis, fever, 
emaciation or loss of weight, localized consolida- 
tion at one or both apices, and the tubercle bacilli 
are present. 

Remember that in abscess of the lung and in pul- 
monary gangrene shreds of lung tissue may be pres- 
ent in the sputum. 



chronic bronchitis. 169 

Treatment. 

The patient should be sent to a warm climate, 
especially for the winter months, if possible. Dur- 
ing cold or wet weather he should remain indoors, 
but should be in the open air on all mild, sunny 
days. 

Flannel should be worn next to the skin. The diet 
should be nutritious and easy of digestion. 

The bowels should be kept open by laxatives if 
necessary. Salines, with an occasional calomel 
purge, is best. 

In cases of dry bronchitis it is better that the 
atmosphere of the room be kept moist by vapors. 

The medicinal treatment depends, first, upon 
whether it is a dry or moist catarrh, and, second, 
upon the underlying condition causing it. In dry 
catarrh the following are useful: 

B Sodii bicarbonatis 3 j 

Sodii chloridi 3 ss 

Ammonii carbonatis 3 ss 

Spiritus chloroformi 3 i j 

Aquae q. s. ad % vj 

Misce et fiat misturse. 

Sig. : 2 tablespoonfuls every four hours in equal amount of 
water. 



Or: 



IJ Pulveris ipecacuanhas gr. j 

Extracti hyoscyaminse . gr. j 

Codeinse phosphatis gr. sj 

Misce et fiat pilula No. I. 

Sig.: Pill at bedtime for cough. 



170 DISEASES OF THE LTOTGS AOT PLEURiE. 

Or: 

IJ Potassii iodidi 3 ss 

Potassii bicarbonatis % ss 

Ammonii cliloridi 3 ij 

Codeinae pbospbatis gr. viij 

Aquae cbloroformi q. s. ad § viij 

Misce et fiat misturae. 

Sig. : Tea spoonful every two bours or tablespoonful every 
four bours. 



Or: 



IJ Olei eucalypti 3 iss-3 iij 

Codeinae pbospbatis gr. vj 

Misce et fiant capsulae No. XVIII. 
Sig.: Capsule every four bours. 

Or: 

IJ Balsami copaibae 3 j-3 ij 

Ammonii cbloridi 3 ij 

Extracti glycyrrbizae pulveris 3 j 

Misturae ammoniacae q. s. ad % iij 

Misce et fiat misturae. 

Sig.: Dessertspoonful every four bours. 

In moist catarrh the expectorants recommended 
in acnte bronchitis, or: 

IJ Terpini bydratis gr. xv 

Alcobolis, 

Aquae, 

Syrupi rubi idaei aa 3 iss 

Misce. 

Sig.: Tablespoonful five times daily. 

Turpentine is excellent, but the kidneys should be 
watched closely: 

IJ Olei terebintbinae 3 j 

Mucilaginis acaciae % ij 

Misturae amygdalae q. s. ad § vj 

Misce. 

Sig. : Tablespoonful two or tbree times daily. 



CHRONIC BRONCHITIS. 171 

Creosote is excellent, especially combined with 
codliver oil. 

Where the bronchitis is of rheumatic or gouty 
origin, the following may be used: 

B Sodii salicylatis 3 vj 

Glycerini 3 iv 

Vini colchici 3 vj 

Syrupi scillse compositse 3 iss 

Tincturse opii camphoratse £ i j 

Misce et fiat misturse. 

Sig. : Teaspoonful with water every two or three hours. 

Benzoic acid or its salts are useful. 

B Terpinolis 3 j 

Sodii benzoatis 5 j 

Extracti glycyrrhizse gr. xx 

Sacchari lactis gr. xxx 

Misce et fiant capsular No. XXX. 

Sig.: 2 to 4 capsules three times daily. 

Or: 

Ifc Terebeni gr. xcvj 

Eucalyptolis T!\ xc 

Syrupi yerba santa q. s. ad £ ij 

Misce. 

Sig.: Teaspoonful every two or three hours. 

Inhalations of antiseptics and deodorants often 
act very beneficially. 

B Thymol gr. xv 

Eucalyptolis TTl, xx 

Creosoti ( Beech wood) 3 ij 

Olei pini sylvestris 3 iv 

Olei gaultherise 3 j 

Misce. 

Sig.: Inhale from small cup while being warmed over a 
spirit lamp. (Merck.) 



172 DISEASES OF THE LUNGS AND PLEURA. 

Or: 

Ifc Mentholis gr. xx 

Eucalypti ill xx 

Chloroformi q. s. ad 3 iv 

Misce. 

Sig.: Inhale 5 to 10 drops from palm of the hand three 
times daily. 

Or: 

B Olei eucalypti Til xxx 

Mentholis gr. x 

Thymol gr. v 

Guaiacolis crystallisati gr. vi j 

Alcoholis q. s. dissolve 

Tincturse benzoini composite q. s. ad § ij 

Misce et fiat misturae. 

Sig. : Float teaspoonful on pint of boiling water in can 
and inhale the steam two times daily. 

Where the pulse is weak and stimulants are 
needed, the elixir of iron, quinin, and strychnin, tea- 
spoonful three times daily after meals, is excellent. 
In emphysema, strychnin is the remedy par excel- 
lence. 

If the bronchitis is due to engorgement from car- 
diac disease, digitalis should be used as outlined 
under treatment of valvular disease of the heart. 

Nephritis, when present as the cause, should be 
treated rather than the bronchitis. 

Bronchiectasis. 

Remember that it very frequently follows attacks 
of grippe. 

Remember that the sputum is expectorated in 
large masses, is greenish-yellow, and has a bad odor. 



BRONCHIECTASIS. 173 

Remember that over the cavities formed by the 
dilatation will be found tympany, the cracked-pot 
sound, bronchial breath sounds with rales, and 
bronchophony. The vocal fremitus is increased. 

Remember that when the cavity fills with secre- 
tions, all the above signs will disappear, but will 
suddenly reappear following a coughing spell and 
expectoration. 

Remember that cavity with signs of catarrh in 
both apices, and sputum brought up frequently in 
small quantities rather than occasionally by mouth- 
fuls, indicate tuberculosis of the lungs. 

Remember that the presence of the tubercle bacilli 
in the sputum is positive sign of phthisis pulmonalis. 

Remember that the cough is absent during the 
day in bronchiectasis and occurs in paroxysms night 
and morning on change of position. 

Remember cerebral abscess is a very frequent com- 
plication in bronchiectasis. 

Treatment. 

Internal antiseptics that are excreted through the 
bronchial mucosa are indicated. Oil of turpentine 
is very effective given in 10 to 15 drops in milk 
three or four times daily, or it may be given in 
capsules, as: 

I£ Olei terebinthinse rectificati TTL x vel TTX xx 

Dentur tales capsulse mollis No. L. 

Sig. : 2 or 3 capsules daily with glass of milk. 

Myrtol, an oily liquid obtained from the leaves 



174 DISEASES OF THE LUNGS AND PLEURAE. 

of the common myrtle, is excellent, acting both as 
antiseptic and deodorant to bronchial secretions. 

IJ Myrtolis TTt ij 

Fiat dosis No. I. Dentur tales capsular mollis No. L. 
Sig. : 3 to 6 capsules daily. 

Eucalyptus, either as a liquid or the oil, is good. 

Ifc Tincturse eucalypti Z ss-3 j 

Syrupi aurantii . . 3 iv 

Aquae destillatse q. s. ad £ vj 

Misce et fiat misturae. 

Sig.: Tablespoonful every two hours. 

Or: 

IJ Olei eucalypti TTt iss-TT|, iv 

Fiat capsula No. I. Dentur tales mollis capsular No. L. 
Sig.: Capsule five or six times daily. 

Remember that sedatives should not be given, lest 
gangrene develop, but ipecac may be used to aid in 
the expulsion of the putrid secretions. The creosote 
vapor bath is very satisfactory in many cases. The 
patient's eyes must be protected by well-fitting 
goggles and the nostrils stuffed with cotton-wool. 
It should be given in a small room. A dram of 
creosote is poured upon water in a saucer and vapor- 
ized by placing over a spirit lamp. The bath should 
be given on alternate days for about fifteen minutes, 
and, if well borne, gradually lengthen the time to 
one hour and give daily. 

Surgical interference is indicated when a single 
large cavity can be definitely localized. It should 
be opened externally and drained. 



BRONCHIAL ASTHMA. 175 

Bronchial Asthma. 

Remember that in some cases there are premoni- 
tory symptoms, such as chilliness, a sense of tight- 
ness in the chest, indigestion, and the passage of a 
large quantity of urine. 

Remember that many of the attacks occur in the 
night and the patient awakes with a sense of suf- 
focation. 

Remember that the dyspnea is expiratory and 
that inspiration is short, but expiration prolonged 
to twice the usual time. 

Remember that the respiratory rate is not in- 
creased. 

Remember that the abdominal muscles are tense 
and hard, being used to assist in expiration. 

Remember that the percussion sound is louder and 
has a peculiar note — the " bandbox' ' sound. 

Remember that the vesicular murmur on ausculta- 
tion is suppressed and may be replaced by bronchial 
breathing. 

Remember that dry, sibilant, sonorous, whistling 
rales are heard on expiration. 

Remember that the appearance of the patient dur- 
ing a paroxysm is quite characteristic — face, pale; 
expression, anxious; speech, impossible; later per- 
spiration, with cold extremities. 

Remember that the sputum is very distinctive. 
Early in the paroxysm it is tenacious, brought up 
with difficulty, and is formed into rounded, gelati- 
nous masses — the pearls of Laennec. 



176 DISEASES OF THE LUNGS AND PLEURA. 

Remember that these gelatinous masses, when un- 
folded, are spirally-arranged molds of the bron- 
chioles. 

Remember that these molds are the Curschmann 
spirals, and microscopically are found to consist of 
filaments of mucin, in which are entangled leuco- 
cytes and the majority of them eosinophils. 

Remember that Charcots crystals are found very 
frequently and often called asthma crystals. They 
are pointed, octohedral crystals. 

Remember that eosinophils of the blood are 
greatly increased. 

Remember that in spasm of the glottis the dyspnea 
is inspiratory, and there are extensive excursions 
of the larynx during respiration and inspiratory re- 
traction of the epigastrium. 

Remember that the tympany from the acute infla- 
tion of the lungs is absent in spasm of the glottis. 

Remember that in bronchial asthma the dyspnea 
is paroxysmal and in the interval respiration is nor- 
mal, while in emphysema of the lungs the respira- 
tory symptoms are continuous. 

Remember that the dyspnea of cardiac asthma is 
both inspiratory and expiratory, and the abnormal 
pulmonic sounds of bronchial asthma are absent in 
cardiac asthma. 

Treatment. 

The treatment divides itself into the treatment of 
an attack and treatment in the interval. Do not pre- 
vent the patient from employing any means which 



BRONCHIAL ASTHMA. 177 

has already proved useful in his case in preventing 
or stopping attacks. 

Treatment of an Attack. 

A hypodermic of morphinae sulphatis gr. %-gr. %, 
with atropine sulphatis gr. %o and spiritus glyc- 
erylis nitratis n\ ij, will give the most prompt and 
reliable results. 

Adrenalin solution (1:1000) rrt v-ni x hypoder- 
matically will usually give prompt relief, but it 
should not be used in arteriosclerosis. 

Chloral hydrate may be used, but the dose re- 
quired (gr. xxx-gr. xl) is entirely too large for 
safety. 

Tobacco smoke, hot coffee, or fresh air often gives 
relief. 

Chloroform inhalations usually act promptly, es- 
pecially in children. 

Pilocarpin gr. % hypodermatically, by producing 
profuse perspiration, will often relax the bronchial 
mucosa. 

Pearls of nitrite of amyl may be broken on a hand- 
kerchief and inhaled; 2 to 5 drops may be used. 

Fluidextract of grindelia hi x-n^ xx is often excel- 
lent, especially if bronchitis be present. 

The leaves of stramonium, belladonna, or hyos- 
cyamus may be made into cigarettes and smoked, or 
they may be powdered and burned in a saucer and 
the smoke inhaled. Saltpeter may be mixed with 
the leaves in a saucer, or the cigarettes may be 



178 DISEASES OF THE LUNGS AND PLEUK.E. 

soaked in a solution of saltpeter and dried, and then 
smoked, as: 

IJ Pulveris stramonii, 

Pulveris belladonna?, 

Pulveris hyoscyaminae, 

Pulveris potassii nitratis aa 3 j 

Misce. 

Sig. : Burn half a teaspoonful in a shovel and inhale 
fumes. 

Interval Treatment. 



If the cause can be detected, it should of course be 
removed or corrected. 

Iodids and belladonna will give better results 
than any other form of medication. 

IJ Potassii iodidi gr. xl 

Tincturae belladonnoe TTt xl 

Spiritus eetheris composite 3 ij 

Aquae q. s. ad % i j 

Misce. 

Sig. : Teaspoonful three or four times daily. 

Or: 

IJ Liquoris potassii arsenitis 3 j 

Tincturae belladonnas 3 j 

Potassii iodidi 3 ij 

Fluidextracti grindeliae (U. S. P.) . .3 vj 

Aquae q. s. ad § iv 

Misce. 

Sig.: Teaspoonful after meals. 

Or: 

IJ Potassii iodidi 3 iiss-3 iv 

Tincturae belladonnas 3 j-3 ij 

Essentias pepsini (Fairchild) q. s. ad 5 iij 

Misce. 

Sig.: Teaspoonful every three hours until relief is per- 
manent. 



BRONCHIAL ASTHMA EDEMA OF LUNGS. 179 

Or: 

I£ Potassii iodidi 3 ij 

Liquoris potassii arsenitis 3 j 

Vini ipecacuanhae 3 ij 

Tincturae hyoscyaminae 3 iv 

Aquae chlorof ormi q. s. ad % viij 

Misce. 

Sig. : Tablespoonful after meals. 

Iron should be administered if anemia be present. 

Ifc Quininae hydrocliloridi gr. xxv 

Ferri carbonatis gr. xxx 

Arseni trioxidi gr. % 

Misce et fiant capsulse No. XV. 

Sig. : Capsule after meals. 

Diet of asthmatics should be simple, as an indis- 
cretion will often cause an attack. 

The bowels must be kept regular, either by the 
use of mineral waters or saline cathartics. 

An equable climate is to be recommended if the 
patient is able to afford it. 

If there is emphysema, high altitudes are not well 
borne and should not be recommended. 

Where chronic bronchitis is present, a warm, dry 
atmosphere is best. In such a climate the open air 
treatment, as used in pulmonary tuberculosis, will 
give best results. 

Edema of the Lungs. 

Remember that, in rare instances, the exudation of 
fluid into the alveoli may be so rapid and abundant 
that dullness, increased pectoral fremitus, bronchial 
breathing, and the signs of complete absence of air 
from the alveoli occur. 



180 DISEASES OF THE LUNGS AND PLEUK^. 

Remember that there are two forms — the inflam- 
matory and that due to engorgement. 

Remember that the onset is usually sudden, with 
rapid breathing, a feeling of oppression, and pain 
in the chest. 

Remember that dyspnea and cyanosis occur — the 
signs of the accumulation of carbon dioxid in the 
blood. 

Remember that rales, moist and bubbling, may be 
heard. 

Remember that the sputum is characteristic, and 
is copious, foamy, and serous (resembling soap 
suds), or it may be blood-tinged. 

Remember that the second pulmonic sound of the 
heart is accentuated, and in that form due to en- 
gorgement the pulse is small. 

Remember that it may prove fatal in a few hours, 
or it may pass off and the patient have recurrence 
of the attack. 

Remember that acute edema of the lung may fol- 
low aspiration of the thorax for the removal of fluid. 

Tkeatment. 

Bleeding is the first and most beneficial procedure 
to be adopted; 6 to 10 ounces of blood should be 
taken. 

Cardiac stimulants, those acting quickest, is the 
next step in treatment. Camphor, ether, or strophan- 
tus are to be given hypodermatically. 

Morphin and atropin are practically a specific in 



EDEMA OF LUNGS LOBAR PNEUMONIA. 181 

many cases. Atropin is especially indicated and 
should be given in a rather large dose. 
Ergot is useful, and may be exhibited as follows: 

I£ Fluidextracti ergotse TTt xlv 

Spiritus setheris 3 j-3 iss 

Aquae cinnamomi q. s. ad g v 

Misce. 

Sig. : Tablespoonful every half to one hour. 

Purging with croton oil irt ij-ni iij on the tongue 
will often assist in checking the transudation of 
fluid. Elaterium may be used. These drastic purga- 
tives should not be used in cardiac disease, and very 
cautiously if nephritis be the cause of the edema. 

Dry cupping and the mustard draft are useful 
adjuncts. 

Lobar Pneumonia. 

Remember that in no other infectious disease is 
a chill so constant or so severe. It usually begins 
suddenly, without any premonitory symptoms. 

Remember that the pain in the side follows close 
after the chill, and is severe, especially when the 
patient coughs. 

Remember that the hurried, shallow breathing is 
often accompanied by a short expiratory grunt. 

Remember that the fever rises rapidly, and 
reaches the fastigium in twelve hours or less. 

Remember that by the end of the second day there 
is the rusty sputum— scanty, viscid, and blood- 
stained. 

Remember that cyanosis and dyspnea occur early, 
due to pulmonary obstruction. 



182 DISEASES OF THE LUNGS AND PLEURA. 

Remember that the respiration rate is greatly in- 
creased, reaching 40 to 60 per minnte. 

Remember that the pulse is strong and full at the 
beginning, but later becomes feeble and small, run- 
ning 90 to 120 per minute. 

Remember that a pulse of 140 to 150 is an un- 
favorable prognostic omen. 

Remember that the pain may be referred to the 
abdomen instead of the chest — very common with 
children. 

Remember that any abdominal pain of sharp, lan- 
cinating character calls for examination of the chest 
for pneumonia. 

Remember that a red spot on the cheek of the 
affected side is very frequently seen in pneumonia, 
and that herpes at the junction of the mucous mem- 
brane and the skin of the lips occurs in nearly half 
the cases. 

Remember that inspection shows a decided differ- 
ence in the expansion of the two sides. 

Remember that marked movement of the chest- 
wall over the affected lung may be observed, due to 
the pulsation of the consolidated lung. 

Remember that pleural friction may be better felt 
than heard, and vocal fremitus on palpation is 
greatly increased in comparison with the corre- 
sponding point on the healthy side. 

Always ask the patient to cough, and thus clear 
the larger tubes, before palpation. 

Remember that percussion reveals pathologic 



LOBAR PNEUMONIA. 183 

changes — viz., Skoda's resonance — found in the 
stage of engorgement. The note is high-pitched 
and has a somewhat tympanitic quality. This may 
also be obtained over the lung tissue bordering 
a consolidated area. In the stage of hepatization 
the note is dull or flat. 

Remember that you never find the wooden flat- 
ness of effusion; neither is the sense of resistance so 
great. 

Remember that on auscultation, early in the dis- 
ease, is heard a fine, crepitant rale — a series of 
minute cracklings heard close to the ear. 

Remember that the crepitant rale is heard at the 
end of inspiration and may not be heard until a full 
breath be drawn. 

Remember that tubular breathing is heard over 
the dull area of consolidation. It is heard first with 
expiration, but later it becomes more intense, of high 
pitch, perfectly dry, and of equal length with in- 
spiration and expiration. 

Remember that the second heart sound over the 
pulmonary artery is accentuated. 

Remember that increased cardiac dullness to the 
right of the sternum and the pulmonary second 
sound becoming less distinct indicate beginning of 
heart failure. 

Remember that the soft, easily compressed pulse, 
with a gray, ashy face, feet and hands cold, clammy 
perspiration, signifies a profound toxemia. 

Remember that there is a diminution of the chlo- 



184 DISEASES OF THE LUNGS AND PLEUE^. 

rids in the urine, and this does not occur in empy- 
ema or pleurisy with effusion. 

Remember that the continuous absence of leuco- 
cytosis is to be regarded as an unfavorable sign. 

Remember that in the old and debilitated the on- 
set is insidious, and the symptoms are ill-defined 
and latent. 

Remember that rapid pulse, rapid respiration, and 
fever call for a careful examination of the chest. 

Remember that in cerebrospinal meningitis there 
are muscular rigidity and retraction of the head. 
Kernig's sign is present and lumbar puncture gives 
a turbid spinal fluid. 

Remember that in a hemorrhagic infarct the blood 
is less thoroughly mixed with the sputum, absence 
of fever, circumscribed dullness, and the presence 
of a condition capable of giving rise to embolism. 

Remember that in edema the sputum is frothy and 
thin, and dullness, if present, is found over the base 
of both lungs posteriorly. 

Remember that broncho-pneumonia usually fol- 
lows some other condition, as measles or other acute 
infectious diseases; comes on gradually without a 
chill, runs an indefinite course and terminates by 
lysis. 

Remember that lobar pneumonia sets in abruptly 
with a chill in a person of previous good health, runs 
an acute course and terminates by crisis. 

Remember that in pleurisy with effusion the on- 
set is with chilliness, but no distinct chill; moderate 



LOBAR PNEUMONIA. 185 

fever; the percussion note is flat, with a peculiar 
sense of inelasticity; vocal fremitus feeble or abol- 
ished, and bronchial breathing distant and faint; 
the S-shaped line of dullness, with a change on a 
change of position of the patient; finally the inser- 
tion of the aspirator needle and the withdrawal of 
fluid settles the diagnosis. 

Remember that in many cases acute tuberculo- 
pneumonic phthisis can not be differentiated until 
softening occurs and elastic fibers and tubercle ba- 
cilli appear in the sputum. The important points 
are heredity, previous cough, and loss of weight; ir- 
regular fever, corresponding to the remittent type 
rather than the continuous; circumscribed areas of 
high-pitched, ringing, coarse, crepitant rales, per- 
sisting with little change, and a mucopurulent, 
greenish sputum. 

Treatment. 

Remember that in the treatment of lobar pneu- 
monia the conservation of the heart is paramount. 

The patient should be isolated, the room should 
be well ventilated, and the temperature of 65° to 
75° F. 

The fresh air treatment lessens cough, improves 
appetite, lowers temperature, and diminishes pulse 
and respiration rate. 

Best in bed, with as little disturbance as possible, 
conserves the vital forces and relieves the heart of 
unnecessary work. 



186 DISEASES OF THE LUNGS AND PLEURA. 

The diet should be nutritious and easily digested. 
Milk should constitute the larger portion. To this 
may be added eggs, meat broths, jellies, and gruels. 

Food should be given at stated, short intervals 
in definite amounts. Plenty of pure water should 
be given throughout the attack, unless evidences of 
cardiac failure develop, when it should be restricted. 

Calomel, either in fractional doses or in one dose 
of 2 to 3 grains, followed by one of the salines, is 
indicated in the beginning; subsequently the bowels 
should be kept free by the use of the salines. 

The skin should be kept active by sponging and 
the kidneys by use of water. 

Pleuritic pain at the onset may be relieved, in 
some cases, by hot or cold applications. Strapping 
of the chest on the affected side with adhesive strips 
gives great relief. Morphin gr. %-gr. 54, with atro- 
pin gr. M.50, will be required to relieve the severe 
pain. 

Tympanites, when it occurs, can often be relieved 
by a careful revision of the diet. A colon tube may 
be used to draw off the gas, or hot turpentine stupes. 
Some of the cases are due to paresis of the muscu- 
lar coat of the intestines, when a hypodermic of 
strychnin nitrate gr. %o three or four times in 
twenty-four hours should be administered. At times 
a hypodermic of eserin will give prompt relief. In 
severe cases a hypodermic of aseptic ergot intra- 
muscularly is of the greatest value. 

Baths should be used. Tepid baths or sponging 



LOBAR PNEUMONIA. 187 

is best. The cold bath should not be used unless the 
temperature is very high. 

Venesection is life-saving in many sthenic cases 
with signs of engorgement and failing right heart. 
The withdrawal of 20 to 30 ounces of blood will re- 
lieve the congestion and tide the patient over his 
critical period. 

Expectorants are not to be given indiscriminately, 
because they derange digestion. 

The dry, irritating cough is best relieved by co- 
dein, and ammonium chloridi will render the sputum 
less tenacious. They are best given in an acid mix- 
ture, as: 

I£ Codeinae sulphatis gr. ii j-gr. v 

Ammonii chloridi 3 iss-3 ij 

Syrupi aeidi citrici o iss 

Aquae q. s. ad g ii j 

Misce. 

Sig. : Teaspoonful every two, three, or four hours as needed. 

If the cough is not troublesome, omit the codein. 
Sleeplessness is usually controlled by sponging or 
bath and fresh air. If the patient is still unable to 
sleep, some hypnotic should be given. If the circu- 
lation is good, trional or sulphonal gr. x in hot milk 
or whisky may be given. Veronal gr. v is safer and 
very efficacious. 

Morphin in small doses should be given where the 
heart is weak. When the heart begins to fail, 
strychnin should be used, but it should not be pushed 
except in emergency. Given hypodermatically, gr. 
Yso every six hours, is best. 



188 DISEASES OF THE LUNGS AND PLEUELE. 

If there is profuse cold sweating, with cardiac 
failure, atropin sulphate gr. % 2 o, repeated every six 
hours, is indicated. 

Whisky or brandy should be given to alcoholics, 
and may be used when cardiac stimulants are indi- 
cated. Half an ounce every three hours until effect. 

Aromatic spirits of ammonia and spirits of min- 
dererus are excellent where mild stimulants are 
needed. 

Digitalis is highly recommended by many in se- 
vere cases. The infusion is probably the best, but 
the tincture, in large doses (ni v-rrt xv) every three 
hours, is used. 

I£ Potassii acetatis 3 j 

Tnf usi digitalis ( leaves ) % iij 

Misce. 

Sig. : Tablespoonful every two or three hours, depending 
upon the severity of the case. 

Or: 

I£ Spiritus anunonii aromatici 3 ss 

Fluidextracti digitalis 3 iiss 

Glycerini q. s. ad 3 iv 

Misce et fiat misturae. 

Sig. : Teaspoonful every three or four hours, or oftener if 
needed. 

Quinin is very generally given in pneumonia. 
Yeo makes very decided claims for it given in an 
effervescent form — in gr. j-gr. iij every three hours. 
His method of prescribing it is as follows: 

B Quininae sulphatis gr. j-gr. iij 

Acidi citrici gr. x-gr. xv 

Sacchari lactis gr. x 

Misce et fiat pulvere No. I. 



LOBAE PNEUMONIA. 189 

This powder is dissolved in a little water and 
added to the following draught: 

I£ Potassii bicarbonatis gr. x-gr. xv 

Ammonii carbonatis gr. iij-gr. v 

Syrupi aurantii 3 j 

Aquse q. s. ad % j 

Misce et fiat haustus. This dose to be given every two or 
three hours. 

The fact that quinin in small doses has been 
shown to increase lencocytosis probably explains its 
beneficial action. Never give large doses, and best 
not given in consolidation. 

Aconite and veratrum are often used in the early 
stage or that of engorgement with the idea of jugu- 
lating the disease. They are best given in small and 
oft-repeated doses, and the alkaloid can be used to 
better advantage. Neither drug should be used after 
the congestion is succeeded by consolidation. 

Creosote, or, better, creosotal (the carbonate), is 
highly extolled. It is taken into the blood and ex- 
creted through the lungs, and thus its germicidal 
action is obtained. It is given in 10-minim doses in 
capsules or in an emulsion. 

At the crisis the collapse following is best over- 
come by hypodermic of atropin. 

Nitroglycerin is especially indicated when the 
urine is scanty and contains more than a trace of 
albumin. 

Notwithstanding its high recommendations, hypo- 
dermoclysis is rarely indicated in pneumonia, and 
the very excellent contraindication exists of too 
much fluid for a tiring heart. 



190 DISEASES OF THE LUNGS AND PLEURAE. 

In convalescence great care should be exercised 
to protect a heart that has been overworked, that 
dilatation may not occur. A return to a full diet 
should be slow, and the patient kept at rest for two 
months after his apparent recovery. 

Broncho-Pneumonia (Lobular Pneumonia). 

Remember that this occurs most frequently at the 
extremes of life, and that it is a terminal event in 
many chronic conditions. 

Remember the frequency with which it follows 
the contagious diseases of childhood. 

Remember that chronic Bright 's disease in the 
aged is often complicated by broncho-pneumonia. 

Remember that the tubercle bacilli often produce 
a fatal broncho-pneumonia. 

Remember that the disease is almost always 
bilateral, while lobar pneumonia is almost always 
unilateral and occurs in adults. 

Remember that if in convalescence from measles 
or in pertussis a child has an accession of fever, with 
cough, rapid pulse, and rapid breathing, and on aus- 
cultation fine rales be heard, a diagnosis of broncho- 
pneumonia should be made. 

Remember that dyspnea is a prominent symptom, 
and the deficiency of air is shown by the rapid respir- 
atory rate. 

Remember that cyanosis develops later, due to ac- 
cumulation of carbon dioxid. 

Remember that the fine, subcrepitant rales are 



BRONCHO-PNEUMONIA . 191 

heard at first, and later tubular breathing over the 
affected areas. 

Remember that percussion usually shows a circum- 
scribed relative dullness, which is usually bilateral, 
radiating along the spinal column. 

Remember that miliary tuberculosis is usually lo- 
calized in the apices of the lungs, and the presence 
of choroidal tubercles in the eye facilitates the diag- 
nosis. 

Treatment. 

The proper care of a child convalescing from 
measles, diphtheria, and whooping-cough will pre- 
vent such a serious complication as broncho-pneu- 
monia. 

Keep the room at an even temperature and the air 
moist with vapor. 

Calomel gr. %o-gr. % should be given hourly until 
a good movement from the bowels is obtained. The 
bowels must be kept open during the illness with 
salines. 

Fever, if high, use water, either as cool sponging, 
pack, and, in severe cases, the bath. Keep ice cap 
to the head. 

Aconite or veratrum, as the tincture, may be used 
cautiously to lower temperature. It is best given 
alone in drop doses every half to one hour in water 
until effect, then every one or two hours. A good 
combination is the following, and it possesses the 
advantage of having a stimulant in combination : 



192 DISEASES OF THE LUNGS AND PLETJK^. 

IJ Aconitin amorphous, 

Veratrini aa gr. % 

Digitalini gr. y 5 

Aquas q. s. ad 5" ij 

Misce et fiat solutio. 

Sig. : Teaspoonful every half hour for 5 doses, then hourly. 

A good saline fever mixture: 

IJ Potassii citratis gr. xxx-gr. 1 

Liquoris ammonii acetatis § j 

Spiritus ammonii aromatici 3 iv 

Syrupi aurantii 3 vj 

Aquae q. s. ad 3" i j 

Misce et fiat solutio. 

Sig.: Teaspoonful every two hours. 

To this may be added sodium bromid if the child 
is nervous. 

Cough is best relieved with codein. 

R. Codeinae phosphatis gr. i j-gr. iv 

Ammonii carbonatis gr. xxx 

Tincturae hyoscyaminae 3 iv 

Syrupi pruni virginianae 3 vj 

Aquae eamphorae q. s. ad 3 ij 

Misce. 

Sig.: Teaspoonful every two hours. 

Or: 

IJ Ammonii carbonatis 3 ij 

Ammonii iodidi 3 iij 

Syrupi glycyrrhizae 5" i j 

Syrupi tolutani 3 ij 

Misce. 

Sig.: Teaspoonful every two or three hours. 

Or: 

B Vini antimonii 3 j 

Spiritus setheris nitrosi 3 iij 

Tincturae opii camphoratae 3 iiss 

Liquoris ammonii acetatis . . q. s. ad % ij 

Misce. 

Sig.: Teaspoonful every two hours for child three to five 
years. 



BRONCHO-PNEUMONIA. 193 

Brandy should be given, best in milk, when stimu- 
lants are needed. 

Diet should be light and nutritious, such as milk, 
broths, and eggs in the form of albumen water. 
Plenty of cold water should be given. A cup of cold 
water should be kept by the bed, and the child en- 
couraged to drink freely. 

If the pulse shows any signs of weakening, brandy 
should be given either in milk or in albumen water. 

Strychnin is indicated in rapid cardiac failure. 
For a child of six months gr. % o should be given 
hypodermatically every three or four hours. 

Tincture of belladonna nx j-irt ij every two or 
three hours is an excellent respiratory stimulant, but 
atropin, combined with strychnin, is much better. 

Venesection is very seldom indicated in children 
or the aged. 

Remember that it is a patient you are treating, not 
pneumonia, and be governed accordingly. 

During convalescence tonics containing iron are 
needed and of these none are better than: 

Ifc Elixiris ferri, quininse et strych- 
ninae phosphatis, 
Essentiae pepsini (Fairchild) . .aagiss 
Misce. 
Sig.: Teaspoonful three times daily. 

Or: 

B Euquinini (Merck) . .gr. xxxv 

Syrupi pruni virginianae 3 iv 

Misce et fiat misturae et adde 

Liquoris potassii arsenitis T^ xxx-fll xl 

Aquae menthae piperitae . . . . q. s. ad g ij 
Misce. 
Sig.: Teaspoonful three times daily after meals. 



194 DISEASES OF THE LUNGS AND PLEURA. 

Chronic Interstitial Pneumonia. 

Remember that the history is very important, as 
it frequently occurs as a sequence of inhalations of 
iron, coal, or stone dust, and in the course of 
syphilis. 

Remember that the characteristic feature of this 
affection is atrophy of the lung. 

Remember that inspection shows retraction of the 
thorax on the affected side, with approximation of 
the ribs, and the spine curved toward the affected 
side. 

Remember that in severe cases there will be drop- 
ping of the shoulder and projection of the scapula, 
together with reduction or absence of respiratory 
movements. 

Remember that in atrophy of the left lung the apex 
beat of the heart is displaced to the left and to a 
higher intercostal space, and the pulsation more dif- 
fuse, because of greater cardiac surface exposure. 

Remember that in the second left interspace over 
the pulmonary artery a systolic bulging and a dias- 
tolic thrill becomes visible and palpable. The thrill 
is due to the closure of the pulmonic valves, and 
auscultation reveals an accentuation of the valve 
sound. 

Remember that if the atrophy is at the apices of 
the lungs, they will be shrunken; and if at the base, 
the abdominal organs adjacent to the diaphragm are 
displaced upward. 



CHRONIC INTERSTITIAL PNEUMONIA. 195 

Remember that examination of the sputum for the 
tubercle bacilli is the only definite way to exclude 
tuberculosis. 

Remember that there will be no shortness of breath 
in the ordinary exercise, but exertion, such as climb- 
ing stairs, may cause dyspnea. 

Remember that chronic cough is always found, but 
there may or may not be abundant sputum. 

Remember that death from hemorrhage or cardiac 
failure may occur. 

Remember that fever, when present, means tuber- 
culosis if not due to other acute associated process. 

Treatment. 

The patient should be protected from changes of 
temperature. It is better to send him to a warm, dry 
climate. The diet must be nutritious and easily di- 
gested. The bowels should be kept regular. The 
skin should be active, and flannel should be worn. 

For the severe cough of the associated bronchitis 
the treatment would be the same as that outlined 
under chronic bronchitis. 

Oil of turpentine gtt. x-gtt. xx three times daily 
is excellent. 

There is nothing that will restore the elasticity of 
the lung. Breathing exercise should be carried out 
to expand the pulmonary tissue. Violent exercise 
should be interdicted because of the danger of 
hemorrhage. 



196 DISEASES OF THE LUNGS AND PLEURAE. 

Emphysema. 

Remember that heredity plays an important role 
in emphysema. 

Remember that bronchitis is a very common as- 
sociate. 

Remember that dyspnea, with harsh, wheezy res- 
piration and prolonged expiration, is characteristic 
of emphysema. The ratio between inspiration and 
expiration, which is normally 1 to 4, may be changed 
to 4 to 1. 

Remember that cyanosis of extreme grade is more 
common in this than in other affections. 

Remember that the inspiratory effort is short, but 
expiratory is greatly prolonged. 

Remember that the large, barrel-shaped chest and 
rounded shoulders, with prominent clavicles and 
deep sternal fossa, are signs of emphysema. 

Remember that the drum-like note on percussion 
is due to the distended air vesicles. The cardiac 
area of dullness is greatly reduced or obliterated, 
and the liver dullness lowered even to the costal 
arch. 

Remember that the breath sounds are feeble and 
soft in character. 

Remember that the obstruction to the lesser cir- 
culation causes hypertrophy of the right heart and 
accentuation of second pulmonic sound. 

Remember that cough and expectoration so often 
found in emphysema are due to the accompanying 
bronchitis. 



emphysema — pulmonary gangrene. 197 

Treatment. 

The obstruction in the lesser circulation will cause 
digestive disturbances; hence the diet should be nu- 
tritious, easily digested, and taken in small amounts, 
but frequently. 

The bowels should be kept open. 

Iron and codliver oil are both indicated, and 
strychnin may be advantageously added. 

Strychnin is admirable, and should be given in 
full doses, beginning with gr. % three times daily 
and increased gradually until gr. % 2 are given. 

Arsenic is good — Fowler 's solution — 5 drops three 
times daily, or arsenic trioxid gr. %o may be used. 

The chronic bronchitis should be treated as al- 
ready outlined. The patient must be carefully pro- 
tected from exposure. 

For asthmatic attacks that so frequently occur a 
hypodermic of morphin sulphate gr. %, with atropin 
sulphate gr. % 2 o, repeated every four to six hours 
if needed, is excellent. 

The main reliance should be placed upon plenty 
of good food, protection from exposure, and the 
free use of strychnin for a long period of time. 

Pulmonary Gangrene. 

Remember that this is a sequence of a variety of 
conditions in the lungs — as lobar pneumonia in the 
debilitated or diabetic patient, aspiration pneu- 
monia, embolism of the pulmonary artery, and it is 
in this manner that gangrene occurs in typhoid. 



198 DISEASES OF THE LUNGS AND PLEUILE. 

Remember that the symptoms of the preliminary 
conditions precede those of gangrene. 

Remember that the sputum is very characteristic, 
usually profuse and fetid. The odor is cadaverous 
or mawkishly sweet and penetrating. 

Remember that pieces of lung tissue can be sepa- 
rated from the sputa. 

Remember that the peculiar plugs seen in the 
sputum in bronchiectasis are absent. 

Remember that elastic fibers are seen with the 
microscope. 

Remember that the color of the sputum is ' ' dirty- 
green, ' ' gray, or brown, depending upon the amount 
of blood it contains. 

Remember that the fever is not high, but the 
pulse is rapid, with great general prostration. 

Treatment. 

The patient should be kept on his back, to avoid 
leakage into sound bronchi. 

The diet should be nutritious, and the strength of 
the patient must be supported. 

Alcoholic stimulation should be used freely. 

Turpentine is excellent, gtt. xv-gtt. xxx, espe- 
cially when there is a complicating hemorrhage. 

Carbolic spray may be used, or better plan is to 
use an inhaler, covering the mouth and nose, and 
charged with a carbolic solution, or with guaiacol 
(or creosote), alcohol, and chloroform, equal parts. 



PULMONARY TUBERCULOSIS. 199 

Creosote may be given both as an antiseptic and 
deodorant. 

I£ Creosoti (Beechwood) TTt xxx 

Alcoholis 3 j 

Glycerini 3 vj 

Aquae q. s. ad 5 viij 

Misce. 

Sig. : Tablespoonful three times daily. 

When the gangrenous area can be located and the 
general condition of the patient is good, surgical in- 
tervention is indicated. 

Pulmonary Tuberculosis. 

Remember that catarrh localized at the apices is 
very suggestive of tubercular infection. 

Remember that dullness on percussion over the 
apex, with the patient in the sitting posture, is sig- 
nificant of early stage of tuberculosis. 

Remember that a deviation from the normal 
sounds on auscultation — as jerky respiration, pro- 
longed expiration, intensified or coarse vesicular 
breathing, or distinct respiratory murmur — is con- 
firmatory of percussion findings. 

Remember that evening elevation of temperature 
is present early in tubercular infection, but the tem- 
perature must be taken at least four times a day. 
The fever may be of the remittent or intermittent 
type. 

Remember that the gradual loss of weight and 
strength in young adults is exceedingly significant 
of phthisis pulmonalis. 



200 DISEASES OF THE LUNGS AND PLEUB2E. 

Remember that "night sweats' ' occur more often 
in phthisis than in any other condition. 

Remember that the examination of the sputum 
will show, in time, the tubercle bacilli and is pathog- 
nomonic of tuberculosis of the lung, but they may 
not be found early in the disease, as they depend 
upon the stage of softening and breaking down of 
infected lung tissue, with expectoration of the pus- 
like material. 

Remember that it is necessary to differentiate the 
formation of a cavity and pneumothorax, especially 
the sacculated form. 

The intercostal spaces over the cavities are re- 
tracted as a rule, while in pneumothorax the inter- 
spaces are bulging, and pectoral fremitus is intensi- 
fied over a cavity, but diminished over pneumo- 
thorax. 

Remember that the cracked-pot sound on percus- 
sion is found over cavities, while distention of the 
thorax, displacement of viscera, especially heart and 
liver, and the change of dullness in the lower por- 
tions upon change of position point to pneumo- 
thorax. 

Remember that cough is present in the majority 
of cases — a dry, hacking cough — but there are no 
characteristic features about it. 

Remember that the "stomach cough" of the dys- 
peptic is probably of tuberculous origin. 

Remember that the rosy cheeks and bright, spark- 
ling eyes accompany the hectic fever of phthisis. 



PULMONARY TUBERCULOSIS. 201 

Remember that Koch 's tuberculin may be used in 
case of doubt to determine the presence of a tuber- 
cular infection. The following method may be fol- 
lowed : for three days the temperature is to be taken 
every three hours and recorded. On the fourth day 
1 milligram of pure tuberculin is injected hypoder- 
matically, and, if no febrile reaction occurs in ten 
or twelve hours, the test is negative. In three days 
twice this amount is injected and the temperature 
watched for twelve hours. This is again repeated 
in three days, using larger dose until finally 5 milli- 
grams are injected at a dose, when, if there be no 
fever, headache, and lassitude, the patient may be 
said to be free of tubercular infection. In positive 
reaction there will be a rise of 2° to 4° F. in the tem- 
perature. 

Do not use tuberculin if a diagnosis is possible 
without it. 

Remember that a rapid pulse and hurried breath- 
ing should arouse suspicion. 

Remember that hemorrhage occurs in the course 
of the disease, and may be the first intimation that 
the patient is tubercular. 

Remember that the muscles overlying an acute, 
active tubercular infection are rigid, similar to the 
condition of the right rectus over an acute inflamed 
appendix. This rigidity is easily detected by light 
palpation of the intercostal spaces. 

Remember that the presence of pain in the chest 
depends upon a coexisting pleurisy. 



202 DISEASES OF THE LUNGS AND PLEURA. 

Always auscultate the lungs posteriorly in the 
interscapular space, as frequently the earliest 
changes of the respiratory murmurs are heard in 
this region. 

Always obtain the family history, because hered- 
ity is of some importance, but continued exposure to 
infection is of great importance in making a diag- 
nosis early. 

Treatment. 

Pulmonary tuberculosis is curable, and, to effect 
a cure, two things are primarily necessary — viz., 
nutrition and ventilation. 

Diet. The food should be highly nutritious, and 
prepared so that it will appeal to the palate. It 
must of necessity be a mixed diet to comply best with 
the above requirements. 

Proteids are of first importance — all kinds of 
meats, and preferably with some fat. 

Eggs are very nutritious, and taken in the form 
of egg-nog are very efficacious, but the patient easily 
tires of eggs, and they must be used liberally in pre- 
paring other foods, as salads, soups, dressings, cus- 
tards, omelets, etc. 

Vegetables — as peas, beans, lentils, and rice — that 
contain large amount of proteid should be given. 

Fats — as butter, cream, oil, bacon, cream cheese, 
fatty cheese — where the fat is easily assimilated, 
should be used. 

Milk in as large a quantity as possible should be 
used — three pints daily at regular intervals. 



PULMONARY TUBERCULOSIS. 203 

Carbohydrates may and should form a good part 
of the dietary. 

Ventilation, or fresh air treatment, is very essen- 
tial. The best fresh air is obtained by being in the 
open air day and night. Sunlight and open air is 
excellent, and the patient should be kept out in the 
sunlight. The bed-room must be so situated as to 
receive as much sunlight as possible. 

The patient must sleep in the open air. This may 
be done by sleeping on a porch, or with the bed at 
an open window so that the head will be in the 
window. There are a number of devices that may 
be attached to the window frame and protect the 
patient's body from exposure in bad weather. 

Exercise must be carefully graded to preserve 
strength and ward off hemorrhage. At most, it 
should be light, and, where there has been great loss 
of strength, resisting exercise and massage is better. 

Care of the Mouth. The patient must be careful 
to cleanse the mouth thoroughly several times a day 
with some antiseptic solution. He should also be 
frequently cautioned against swallowing the sputum, 
but should spit it into a cuspidor containing some 
antiseptic solution or into a piece of cotton and 
burned. The dishes and drinking cups of the pa- 
tient should be scalded after use. In brief, every- 
thing must be done to prevent the patient reinfecting 
himself, so that he may escape fresh lesions. 

Medicinal Therapy. Creosote and codliver oil 
probably lead in therapy of tuberculosis. Creosote 
may be used both internally and by inhalations. 



204 DISEASES OF THE LUXGS AXD PLEURA. 

B Creosoti (Beechwood) gtt. vj 

Glyeerini 3 j 

Spiritus f rumenti % i j 

Misce. 

Sig. : Dessertspoonful diluted with water every two, three, 
or four hours. 

The dose of creosote may be increased, but large 
doses should never be given, nor should the drug be 
pushed to the point of toleration because of the re- 
action from the drug. If the patient receives any 
benefit from creosote, it is manifested by increased 
appetite, improved nutrition, weight added, expec- 
toration diminished, pus in the sputum lessened, 
the disappearance of bad odor from the sputum, 
and associated nontuberculous laryngitis, tracheitis, 
and bronchitis of the larger tubes cured. 

"When too much creosote is taken, there will be 
loss of appetite, coated tongue, nausea, vomiting, 
yellow tinge of the sclera, due to sluggish liver, and 
sugar or albumin may appear in the urine. The pa- 
tient must be studied while taking the drug to de- 
termine whether it should be continued. 

Inhalations of creosote may be administered 
either alone or in combination with other well- 
known medicaments. 



B Creosoti (Beechwood), 
Alcoholis, 

Spiritus ehloroformi aa 3 j 

Misce. 

Sig.: 10 drops on a sponge or inhaler; inhale at first fre- 
quently for fifteen minutes at a time and gradually lengthen 
the time to one hour. 



PULMONAKY TUBERCULOSIS. 205 

Or: 

I£ Creosoti ( Beech wood ) HI xv 

Tincturae benzoini composite % iij 

Misee. 

Sig. : Teaspoonful floated on cup of boiling water and steam 
inhaled three or four times daily. Shake. 

Or: 

I£ Creosoti ( Beechwood ) Tit vi j 

Olei pini sylvestris 3 iiss 

Tincturse benzoini composite q. s. ad 3 iij 
Misce. 

Sig.: Teaspoonful on boiling water and inhaled three 
or four times daily. Shake. 

Or: 

Ifc Creosoti (Beechwood) 1TJ, x 

Olei pini sylvestris, 

Olei terebinthinae aa 3 iiss 

Tincturae benzoini composite q. s. ad g iv 
Misce. 

Sig. : Teaspoonful on boiling water and inhaled three or four 
times daily. Shake. 

Creosote for internal use may be combined as fol- 
lows: 

B Creosoti (Beechwood) Tl\ j-TH, ij 

Olei olivae vel olei morrhuse Tl| ij-TTj, v 

Misce et fiat capsula No. I. Dentur tales capsular mollis 
No. L. 

Sig.: 3 to 7 capsules three times daily after food. 

Or: 

B Creosoti ( Beechwood ) 3 iv 

Tincturae gentianae compositae g j 

Alcoholis % vii j 

Vini xerici q. s. ad i j 

Misce et fiat solutio. 

Sig.: 2, 4c } or 6 tablespoonfuls three times daily after 
meals in glass of milk. 



206 DISEASES OF THE LUNGS AND PLEUEiE. 

Or: 

IJ Creosoti ( Beechwood ) 3 ss-3 j 

Olei morrhuee § vj 

Aeacise, 

Aquse menthse piperitse aa q. s. 

Misce et fiat emulsio. 

Sig. : Tablespoonful three to five times daily. 

Guaiacol, a creosote derivative, may be used. 
Some of the salts, usually the carbonate or salicy- 
late, are most frequently given. 

I£ Guaiacolis carbonatis or salicylatis gr. vij 
Fiat capsula No. I. Dentur tales capsular No. L. 
Sig.: 2 to 12 capsules daily. 

Creosotal is frequently better borne by the 
stomach, and may be prescribed. 

Ifc Creosotalis 3 ii j 

Sig. : Half teaspoonful three to five times daily in milk. 

Or: 

fy Creosotalis 3 v 

Olei morrhuse 3 iij 

Acaciae, 

Aquas menthas piperitse . . aa q. s. ad 3 vj 
Misce et fiat emulsio. 
Sig.: Tablespoonful three to six times daily after meals. 

There are a number of drugs to be used in tuber- 
culosis, partly to keep up nutrition and partly to 
replace certain substances excreted in abnormally 
large amounts. 

Arsenic is first. Either in pill form or Fowler's 
solution. It stimulates nutrition and is an excellent 
general tonic. 

Salt. Patient should be instructed to use large 



PULMONARY TUBERCULOSIS. 207 

quantity of table salt to replace the abnormal loss 
in sputum and urine. 

The phosphates should also be given. The best 
are the pharmacopeial preparations : 

I£ Syrupi hypophosphitis S vj 

Or: 

B- Syrupi caleii lactophosphitis g vj 

Sig. : To be given in teaspoonful doses three times daily. 

Anorexia must be combated. It is important that 
nutrition be maintained. If high fever is the cause 
of the anorexia, food should be given at the time the 
temperature is down and endeavor must be made to 
reduce the fever. If pain on swallowing or cough 
interfere with the taking of food, narcotics should 
be given before meals. Stomachics may be used to 
combat anorexia, as: 

B Tincturae nucis vomicae 3 i j 

Tincturae gentianae compositae, 

Tincturae cinchonae comp. aa q. s. ad 3 iij 
Misce. 
Sig. : Half teaspoonful before meals. 

Fever. Drugs should not be given to reduce tem- 
perature until rest in bed and fresh air have failed, 
Unless fever is high and interferes with nutrition 
or causes unpleasant symptoms, no attempt should 
be made to reduce it. When high, the diet should 
be liquid, but should be plentiful. 

Pyramidon gr. j-gr. iij every three hours until 
effect, or one single large dose gr. xv dissolved in 
hot water. This is the safest and best drug to be 
used. 



208 DISEASES OF THE LUNGS AND PLEURA. 

Other coal-tar derivatives may be used, but, when 
antipyriu or phenacetiu are used and appear to in- 
crease diaphoresis, it is best to change to other 
methods, or give them in much smaller doses. 

Hydropathic measures for reducing fever are not 
used to any great extent in phthisis. Sponging the 
body under cover may be used. 

Night Sweats. Sponging with equal parts of 
water and alcohol on going to bed, and, if necessary, 
during the night, may prevent them. Brandy, a tea- 
spoonful in a cup of hot or cold milk, may be given 
at bedtime. An ounce of whisky may be adminis- 
tered a short time before the expected sweat. 

Atropin sulphate gr. M.50 in tablets may be given 
hourly in the evening for 4 or 5 doses. 

Agaricin may be used, but, owing to its tendency 
to produce diarrhea, it is better to combine it with 
Dover's powder. 

R Agaricini gr. iij 

Pulveris Doveri gr. xyx 

Althsese, 

Mucilaginis acacise aa q. s. 

Misce et fiat massa. Divide pilulae No. XX. 

Sig. : 1 or 2 pills five hours before the expected sweat. 

Camphoric acid has the advantage of producing 
quick effect, which lasts for six hours. It is given 
in capsule of 1 or 2 grains in the evening. 

A dusting powder of either tannoform or zinc 
peroxid, to be dusted over the skin, is often very 
beneficial in checking the sweat 



PULMOKAKY TUBEECULOSIS. 209 

Ifc Zinci peroxidi 5 j 

Talci purificati E iss 

Misce et fiat pulveris. 

Sig.: To be dusted on the skin. 

Cough. Is often torturous and prevents rest. 
Patient should be taught how to cough to raise 
sputum by a deep, slow inspiration, followed by a 
short, quick expiration. 

When the nose, pharynx, or larynx is not the 
cause, then codein should be used to check it. Some- 
times local treatment to the upper portion of the 
respiratory tract is all that is necessary. 

I£ Codeinae phosphatis gr. vii j 

Acidi hydrocyanici diluti 3 j 

Spiritus chloroformi 3 iss 

Syrupi lemonis 8 j 

Aquae q. s. ad 3 iv 

Misce. 

Sig.: Teaspoonful when cough is troublesome. 

Or: 

Ifc Dionini gr. iv 

Acidi hydrocyanici diluti Tit xxx 

Syrupi tolutani 3 vi 

Aquae q. s. ad % ij 

Misce. 

Sig. : Teaspoonful every three hours for cough. 

Hemorrhage is best treated by recumbent posture 
of the patient, with head propped up, and positive 
assurance of the physician that all will be right. 
Place an ice bag over the pericardium to quiet the 
heart and give hypodermic of morphin gr. %-gr. %. 
Nitroglycerin to lower blood pressure is recom- 
mended by some. 



210 DISEASES OF THE LUNGS AND PLEURAE. 

Calcium lactate in half -dram doses three times a 
day for two days may stop repeated small hemor- 
rhages. 

Adrenalin hypodermatically and salt solution 
should be used when large hemorrhage endangers 
life. 

Mercurial Treatment of Tuberculosis. 

Excellent results are reported from the new Fort 
Lyon Naval Hospital by hypodermatic use of mer- 
cury succinimide. Two strengths are used — gr. %o 
and gr. % to the tablet. One injection of gr. % is 
given every other day until thirty injections have 
been given; then one week's rest, when injections 
are resumed, using gr. % and gr. V 10 alternately, 
and later gr. M.o was used. A later method has been 
advised of administering the drug in gradually in- 
creasing doses until the therapeutic limit is reached. 
"When the maximum dose for the patient is estab- 
lished, it is divided by two and the injections con- 
tinued on this basis. The open air and food treat- 
ment is also carried out in conjunction with the 
mercury treatment. 

At present it is better not to attempt the use of 
tuberculin as a curative measure. 

As to the advisability of sending tubercular pa- 
tients away from home, we are strongly opposed. 
Nothing can be worse than to be seriously sick in a 
strange land among strangers. There is nothing to 
be gained away from home that can not be had at 



PULMONARY TUBERCULOSIS ACUTE PLEURISY. 211 

home. There are many devices to apply to a win- 
dow and to the patient's bed in snch a manner that 
the head and shoulders are in the open air, while 
the body is protected. 

Finally, let ns urge a, careful supervision by the 
attending physician of the patient's sputum. Let 
the short, concise statement ring in our ears, "No 
sputum, no tuberculosis." A piece of paper, rectan- 
gular in shape, rolled cornerwise so as to form a 
funnel, and the pointed end doubled back, makes an 
excellent spit cup, that should be used and thrown 
into the fire. 

Acute Pleurisy. 

Remember that in children or the aged the only 
symptoms that may be present are dyspnea on exer- 
tion and increasing pallor. 

Remember that chill, fever, and pain, or "stitch 
in the side, ' ' usually announce the onset of pleurisy. 

Remember that the pain is sharp and lancinating, 
and the cough makes it worse. 

Remember that on auscultation a dry, friction rub 
is heard prior to the exudate, and this friction sound 
is pathognomonic. 

Remember that fever does not rise so rapidly nor 
so high as in pneumonia. 

Remember that the pain may be felt in the abdo- 
men or low down in the back. 

Don't mistake the dry, crepitant rales for the 
friction sound. The friction sound is not continu- 



212 DISEASES OF THE LUNGS AND PLEURAE. 

ous, and not restricted to inspiration as are crepitant 
rales, but is divided between inspiration and expira- 
tion, and is distinguished as being very superficial, 
or close to the ear. Coughing up the secretions has 
no effect upon the pleuritic sound. 

Remember that effusion into the pleural sac causes 
marked changes. The friction rub heard on auscul- 
tation, and so characteristic of pleurisy in the early 
stage, disappears. 

Remember that bulging of the intercostal spaces 
signifies effusion. 

Remember that the patient changes posture, and 
now lies on the affected side to give more freedom 
in breathing. 

Remember that on auscultation the breath sounds 
are distant and tubular, and vocal resonance on pal- 
pation is diminished or absent. 

Remember that the dullness on percussion over 
an effusion is flat, and there is a sense of resistance 
to the fingers. 

Remember Grocco's triangle of dullness in effu- 
sion. It is found along the spine on the side oppo- 
site the effusion, and from one-quarter to one inch 
wide, with apex upward. It is due to the displace- 
ment of the mediastinum by the fluid. The patient 
should be in the sitting posture. 

Remember that Skoda 's resonance is found just 
above the line of effusion, posteriorly as well as in 
the subclavicular space. It is a tympanitic note, 
due to the compression of the lung. 



ACUTE PLEURISY. 213 

Remember that the insertion of the hypodermic 
needle nnder aseptic precautions and the withdrawal 
of fluid determines two points — viz., an effusion and 
whether serous or purulent. 

Remember that liquid in pleural sac will cause 
displacement of organs, and the cardiac displace- 
ment is the one most easily determined. 

Remember that in a tumor of the mediastinum the 
dullness usually extends from below upward, is 
irregular in outline, and not restricted to one side. 

Remember that as the tumor grows there will be 
compression of nerves, vessels, and esophagus. 

Remember the following points in differentiating 
pleurisy and pneumonia: 

1. Dullness of pleurisy is absolute (woody), offer- 
ing great resistance on percussion. 

2. Pectoral fremitus absent or diminished over an 
effusion. 

3. Crepitant rale is absent in pleurisy. 

4. Displacement of organs is marked in effusion. 

5. Sputum of pneumonia always present and 
rusty-colored. 

6. Fever of pneumonia is high. 

Treatment. 

Patient should be put to bed. 

Pain in the early stages is the most urgent symp- 
tom for treatment. 

A hypodermic of morphin is the best way to re- 
lieve it. 



214 DISEASES OF THE LUNGS AIST) PLEURA. 

The ice bag to the affected side, leeches, hot 
fomentations, or mustard plaster will give relief 
where pain is not severe. 

Immobilizing the side gives prompt relief. Ad- 
hesive strips are used. They are cut long — long 
enough to extend about two inches beyond the me- 
dian line posteriorly and anteriorly. The three-inch 
is best, and the strips should overlap one-third. 
They should be applied with the lungs as near col- 
lapsed as possible — at complete expiration — begin- 
ning at the lower margin and strapping upward 
until the axilla is reached. 

Calomel, followed by saline, should be given. 

Diet should be light. When effusion occurs, it 
should be dry. No liquids be given. Concentrated 
saline purges should be given in the morning before 
breakfast. Salt should be withheld. 

Effusion is best relieved by aspiration. An ordi- 
nary trocar may be used or Potain's aspirating set 
may be obtained. The site depends upon the loca- 
tion of the liquid — usually in the midaxillary line, 
in the seventh intercostal space. The skin is thor- 
oughly cleansed. The patient places the hand of 
the affected side on the shoulder of the opposite 
side, thus widening the intercostal spaces. The 
needle is thrust in close to the upper margin of the 
rib, so as to avoid wounding the artery. The amount 
of fluid to be drawn off depends upon the reaction 
of the patient. All of a large exudate should not 
be withdrawn at one time, as a severe paroxysm of 



ACUTE PLEURISY. 215 

coughing is caused by sudden relief of the pressure 
upon the lung. 

In early stage, when fever and circulatory excite- 
ment exist before effusion occurs, the following 
may be administered: 

B Tincturse aconiti Til x 

Spiritus aetheris nitrosi 3 j 

Syrupi pruni virginianas 3 iv 

Liquoris potassii citratis . . q. s. ad 3 ii j 
Misce. 

Sig. : Tablespoonful hourly until pulse becomes soft, then 
every two hours. 

Or: 

I£ Potassii citratis 3 v 

Antipyrini 3 j 

Liquoris ammonii acetatis % iij 

Syrupi limonis % ij 

Aquae q. s. ad 3 viij 

Misce. 

Sig.: Tablespoonful hourly for four doses, then every 
two or three hours. 

Iodid of potash and sodium salicylate are of little 
benefit, although frequently used. They are very 
liable to upset the stomach. 



CHAPTER XI. 

INFECTIOUS DISEASES. 

Typhoid (Enteric Fever). 

Remember that, while the disease is more common 
in early adults, the disease is often seen in children. 

Remember that in children there is frequently ab- 
sent some of the usually constant symptoms. 

Remember that the onset in children may be so 
sudden and the diarrhea so severe that acute en- 
teritis is diagnosed. 

Remember that, as a rule, the onset is gradual, 
and that for ten days or two weeks there are lassi- 
tude and inaptitude for work. 

Remember that nose bleed is an early and fairly 
constant sign in typhoid, especially when the pa- 
tient is not subject to epistaxis in health. 

Remember that headache is an early and fairly 
constant symptom, and occasionally it may be very 
severe, accompanied by photophobia, retraction of 
the head, and muscular twitching, suggesting menin- 
gitis. 

Remember that severe facial neuralgia may mark 
the onset of typhoid. 

Remember that the first intimation may be acute 
mania, pronounced delirium, or drowsiness and 
stupor, simulating basilar meningitis. 

Remember that an initial bronchitis is very com- 

216 



TYPHOID. 217 

mon in typhoid, but occasionally it is of so great a 
severity as to obscure other features of the disease. 

Remember that the onset may be by a chill, pain 
in the side, hurried breathing, and pleurisy, or pneu- 
monia may be suspected. 

Remember that severe abdominal pain and tender- 
ness in the appendiceal region has led to a diag- 
nosis of appendicitis. 

Remember that at the beginning of typhoid the 
cheeks are flushed and the eyes are bright, but at 
the close of the first week we find the dull, heavy 
look so familiar. 

Remember that the fever may not be of the ordi- 
nary type. There may be a rapid rise to 103° or 
104° F. following a chill or convulsion. Usually the 
"step-ladder" rise of the temperature from day to 
day during the first week is observed. 

Remember that after the fastigium is reached the 
fever continues with but slight daily remissions. As 
a rule, the fever terminates by lysis, but it may dis- 
appear rapidly and in twenty-four hours the tem- 
perature be normal. This may be associated with 
severe sweating. 

Remember that a sudden drop in the temperature 
strongly indicates intestinal hemorrhage. 

Remember that "rose spots" are not present in 
all cases of typhoid, but that when present they are 
pathognomonic of the infection. They are small red 
spots found on the abdomen, that disappear on pres- 
sure and come in crops. They make their appear- 



218 INFECTIOUS DISEASES. 

ance from the seventh to the tenth day. There may 
be few on the abdomen and the eruption may be 
general. 

Remember that while a dry, hot skin is usually 
found at the height of the fever, there are cases 
where sweating is characteristic; usually associated 
with chilly sensations. 

Remember that paroxysms of chills, fever, and 
sweats may occur, and thus simulate malaria, but 
they are lacking in periodicity and may occur sev- 
eral times in the twenty-four hours. 

Remember that the dicrotic pulse is more often 
found in typhoid than in any other condition, and 
that the increase of the pulse rate is not propor- 
tionate to the increased temperature. 

Remember that an enlarged, soft spleen is an al- 
most constant clinical symptom of typhoid. If the 
vertical dullness over the splenic area exceeds the 
depth of two ribs and an interspace, enlargement is 
present. The best way to determine enlargement is 
by palpation. 

Remember that the " pea-soup" stools occur in 
the second week, as does also status typhosus — 
stupor, somnolence, difficulty of hearing, indistinct- 
ness of speech, muttering delirium, and picking at 
the bed clothes. 

Remember that the agglutination test of Widal is 
the most conclusive sign we have of typhoid infec- 
tion. 

Remember that the results of the test are just as 



TYPHOID. 219 

good if you use cultures of dead bacilli, and the 
microscope is not needed to determine a positive or 
negative reaction. 

Remember that many tests should be made in 
case the first proves negative, because the formation 
of antibodies is often delayed and the reaction not 
obtained until late in the disease. 

Remember that a sudden drop in the temperature, 
feeble and rapid pulse, and pallor are unequivocal 
signs of hemorrhage, even though it has not yet 
appeared in the stools. This accident most often 
occurs in the second or third week of the course of 
the disease. 

Remember that the signs of perforation are never 
the same as those of peritonitis, and it is reprehen- 
sible for a physician to await the onset of the latter, 
as the few hours intervening between the occurrence 
of the one and the onset of the other are the life- 
saving hours. 

Remember that the signs of perforation are : 

1. A sharp, severe pain, often paroxysmal in 
character, in the hypogastric region and to the right 
of the median line. 

2. Tenderness on pressure, most marked in the 
hypogastrium. 

3. Muscular rigidity on light palpation. 

4. Drop in the temperature, sweating, and increase 
rate of pulse and respiration. 

Remember that at this period the patient becomes 
an urgent case for the surgeon and ceases to be a 
proper case for the internist. 



220 INFECTIOUS DISEASES. 

Remember that after four to six hours peritonitis 
follows perforation; the temperature rises; balloon- 
ing of abdomen; disappearance of liver dullness; 
muscular rigidity; rapid, feeble pulse; cold sweat — 
death. 

Treatment. 

Diet. There are two views relative to the diet. 
On the one hand, we have those who restrict the 
diet to liquid. A representative of this type is the 
one used by Osier and McCrea, consisting of 4 
to 6 ounces of milk, diluted with 2 ounces of 
lime water, every four hours, and 4 ounces of 
albumen water, made from the white of one or two 
eggs, every four hours. They claim that even that 
amount is probably too much. On the other hand, 
a number of excellent physicians are using a more 
liberal diet — treating the patient rather than the 
disease. Dr. F. C. Shattuck's menu may be quoted 
as representing this view: 

1. Milk — hot, cold, diluted with lime water, soda 
water; peptonized milk; cream and water; milk with 
white of egg; buttermilk; matzoon; milk whey; milk 
with tea, coffee, or cocoa. 

2. Soups — beef, veal, chicken, tomato, potato, oys- 
ter, mutton, pea, bean, squash; carefully strained 
and thickened with arrow-root, flour, milk or cream, 
egg, barley. 

3. Malted milk— Horlick 's, Mellin's. 

4. Beef juice. 



TYPHOID. 221 

5. Gruels — strained cornmeal, crackers, flour, bar- 
ley water, toast water, albumen water with lemon 
juice. 

6. Ice cream. 

7. Egg — soft boiled or raw; egg-nog. 

8. Finally, minced lean meat, scraped beef, the 
soft part of raw oysters, soft toast, jelly, apple sauce, 
and macaroni. 

It is probably true that we have been feeding too 
little and the patient enters upon his period of con- 
valescence handicapped. 

Liquids. Typhoid patients must be given water 
freely, unless contraindicated by extreme arterio- 
sclerosis, myocarditis, or serious valvular lesion. 
In addition to the liquid in the food, they should be 
given from a half to two quarts daily. The severer 
the toxemia, the more water should be given. 

Lemonade is excellent, because it excites the flow 
of saliva and prevents the mouth becoming dry. 

Alcohol should be given in cases of profound 
toxemia and the heart feeble; 8 to 12 ounces of 
whisky may be given in the twenty-four hours. One 
strong indorsement for a liberal diet is the fact that 
the patient seldom needs whisky. 

Where the tub bath is used and the patient re- 
quires whisky, it should be given just before or after 
the bath, depending upon his reaction to the bath. 

Hydrotherapy. This is next in importance to the 
diet. The bath, cold packs, or sponging may be used. 
Of the various methods of applying water, the bath 
is best when not contraindicated. 



222 INFECTIOUS DISEASES. 

Baths. Are not only given to reduce the tempera- 
ture, but they mitigate the nervous symptoms, and 
thus lessen the delirium, stimulate the kidneys, and 
thus increase the excretions of toxins, and cleanse 
the skin — in short, affect favorably the whole course 
of the disease. It is best to begin with water at 80° 
or 85° F., and gradually reduce the temperature 
after placing the patient in the tub. Always apply 
cold to the head. Gently, but briskly, rub the pa- 
tient while in the bath. The bath should last from 
ten to fifteen minutes, and the patient is placed be- 
tween sheets and covered with a blanket after 
removal and drying. The temperature should be 
taken immediately after the bath and again in an 
hour. These baths may be repeated as often as the 
temperature reaches 103° F. A cup of hot milk may 
be given and hot-water bottle placed to the feet. 

Cold Packs. A sheet is wrung out of cold water 
and the patient wrapped in it. The head and feet 
are left free. Cold water may be sprinkled over 
him occasionally, or he may be rubbed with a piece 
of ice, especially along the vertebrae. The pack is 
removed in from twenty to thirty minutes, the body 
dried and covered with sheet and blanket. 

This may be repeated as often as the temperature 
indicates it. Cool sponging may be resorted to in 
mild cases. Alcohol or vinegar should be added to 
the water. The skin should be only partially dried, 
so that by evaporation of the moisture on the skin 
a continuation of the antipyretic effect may be ob- 
tained. 



TYPHOID. 223 

Contraindications for cold baths or packs are in- 
testinal hemorrhage, perforation, the old and very 
young; patients suffering with acute or serious 
chronic cardiac or cardiovascular changes, phlebitis, 
nephritis, pneumonia, pregnancy; very obese, ane- 
mic, and alcoholics. 

Medicinal Antipyretics. These should not be 
given unless baths can not be used, either because 
of contraindications or prejudices of the family. 
There are a number of drugs that are antipyretic — 
quinin, phenacetin, antipyrin, pyramidon. 

Quinin should not be given to typhoid patients in 
doses large enough to reduce temperature. From 
recent laboratory reports quinin in 2-grain doses 
every three hours will stimulate phagocytosis, and 
perhaps will thus assist the body in fighting the 
invaders, but the dose is too small to affect the 
fever; and the laboratory has also shown that quinin 
in large doses destroys the ameboid movement of 
leucocytes, and thus interferes with the resisting 
forces. 

Antipyrin and phenacetin are better not used in 
typhoid, because of the cardiac depressing effect. 

Pyramidon is given gr. iij-gr. iv every two or 
three hours, and it is claimed by good observers to 
have no ill effect, except that in some patients it 
produces excessive diaphoresis. As a precaution, it 
may be combined with 3 to 4 grains of sodium ben- 
zoate of caffein. 

Calomel should be given at the onset, and repeated 



224 INFECTIOUS DISEASES. 

throughout the disease when tympany indicates ex- 
tensive gas formation in the bowel. Gr. v-gr. x may 
be given in one dose, or it may be administered in 
broken doses. Nobody claims it cuts short the 
course of typhoid, but the experience of clinicians 
is favorable to its use because of its combined 
powers as an antiseptic, glandular stimulant, and 
eliminant both through the bowels and kidneys. 

Intestinal antiseptics are indicated, but not, as 
some think, to cut short the disease nor to abort it. 
They reduce the bacterial activity in the intestines 
and thus favorably influence the disease. Turpen- 
tine in emulsion is best and the sulphocarbolates 
follow. 

The following are excellent combinations: 

B Naphtolis 3 j 

Salolis . . . . gr. xxx 

Pulveris aromaticse gr. xx 

Misce et fiant pulveres No. XII. 

Sig. : Powder every four hours. 



Or 



I£ Bismuthi salicylates 3 ii j 

Ichthalbini 3 iij 

Sacchari lactis 3 j 

Misce et fiant pulveres No. XXIV. 

Sig.: Powder every four hours. 



Or 



B Sodii sulphocarbolatis 3 iij 

Resorcinolis (Merck) gr. xxx 

Syrupi simplicis § ij 

Aquse menthae piperitae % iv 

Misce. 

Sig.: Tablespoonful every four hours. 



TYPHOID. 225 



Or: 



B Zinci sulphoearbolatis gr. ss 

Calcii sulphoearbolatis gr. j 

Sodii sulphoearbolatis gr. iiiss 

Bismuthi salicylatis gr. % 

Mentholis gr. j 

Misce et fiat pulvere No. I. 

Sig. : Powder every three to six hours, according to odor 
of stools. 

This combination is put up in tablet form by 
Abbott, and is very convenient and effective. Or: 

B Olei terebinthinaB 3 iss 

Olei caryophylli gtt. vj 

Glycerini, 

Mucilaginis acacise aa § ss 

Aquas destillatae q. s. ad 5 ii j 

Misce et fiat misturae. 

Sig. : Dessertspoonful every two hours during the day. 

Thymol is preferred by some, because it possesses 
antiseptic power four times as great as carbolic 
acid and is innoxious; it is also insoluble, so that it 
reaches the intestines. It is given in gr. ij-gr. iij 
every three hours, made into a pill, and should al- 
ways be given with food. 

Mouth, teeth, and tongue should be thoroughly 
cleansed after each feeding. The mouth and teeth 
should be washed with weak alkaline solution. Bak- 
ing soda in warm water is excellent, and, if the pa- 
tient is able, he should rinse the mouth with some 
mild antiseptic solution. 

Bed sores are rare where bathing is used in the 
treatment. It is well to rub the skin over the but- 
tocks, thighs, and lower back with a weak bichlorid 



226 INFECTIOUS DISEASES. 

solution, followed with alcohol; rub dry and dust 
with some simple powder or talcum. 

Diarrhea demands treatment when the daily 
evacuations exceed six. Silver nitrate gr. /4-gr. V2 
is called a specific by some. Bismuth subnitrate or 
salicylate gr. v-gr. x, with paregoric 3 ss, every two 
or three hours, is useful, or the following: 

B Pulveris opii gr. % 

Pulveris camphorse gr. j 

Plumb i acetatis gr. iij 

Bismuthi subnitratis gr. xxx 

Misce et fiat pulvere No. I. Dentur tales pulveres No. XII. 

Sig. : Powder every four hours. 

Or: 

Ifc Bismuthi subnitratis 3 i j 

Tannalbini 3 iij 

Dionini gr. ij 

Misce et fiant pulveres No. XII. 
Sig.: Powder every three hours. 

Meteorism. First insert a large rubber catheter. 
Turpentine stupe to the abdomen. A careful re- 
vision of the diet — as the omission of gruels and 
peptonizing of the milk. Eserin gr. % may be 
given. 

Hemorrhage. Apply cold to abdomen — as light 
ice bag. Stop everything by mouth, except cold albu- 
men water. If patient is restless, give morphin hy- 
podermatically. Administer calcium salts in large 
doses. In large hemorrhage, manifested by weak, 
rapid pulse and signs of collapse, give saline solu- 
tion into the subcutaneous tissues or into the vein, 
according to the urgency of the case. It is best to 



TYPHOID BACILLARY DYSENTERY. 227 

omit the morphin if possible, and in no case should 
the sensorium be completely obtunded, because per- 
foration may occur and pain is our principal guide. 

R Stypticini gr. xij 

Ergotini gr. xxx 

Elixiris simplicis 5 ii j 

Misce. 

Sig. : Tablespoonful every two to three hours. 

Perforation requires an immediate operation, un- 
der general anesthesia if possible or under cocain. 
There can be no delay, as peritonitis will inevitably 
follow in five or six hours. 

Urotropin gr. v-gr. x should be administered three 
times daily for its antiseptic powers in the bile, 
urine, and cerebrospinal fluid. Many cases of gall- 
stones will thus be prevented and the urine will not 
become a distributor of the germs. This drug should 
be administered during the period of convalescence 
as well. 

Tonics, and good food and fresh air in abundance 
should be given the convalescent. 

Children should not be returned to school before 
six months following typhoid. 

Bacillary Dysentery. 

Remember that this affection often appears in 
epidemics, in which children are attacked as well as 
adults. 

Remember that hot weather and improper feed- 
ing of children is a very frequent cause. 

Remember that the onset is usually sudden, and 



228 INFECTIOUS DISEASES. 

is characterized by slight fever, pain in the ab- 
domen, and frequent stools. 

Remember that the stools at first contain a large 
amount of mucus, but in twenty-four hours blood is 
passed with it. 

Remember that frequently pure blood is passed; 
hence "bloody flux." 

Remember that there is a constant desire to go to 
stool. The motion of the bowels affords no relief. 

Remember that straining and tenesmus while at 
stool is very characteristic. 

Remember that the temperature gradually rises, 
and the pulse becomes rapid and small. 

Remember that the frequent stools cause great 
thirst and rapid emaciation. 

Remember that the blood of the patient in dilu- 
tion will agglutinate the Flexner-Harris or Shiga 
bacilli, depending upon the bacilli causing the in- 
fection. 

Remember that the bacilli dysenterise should be 
sought for with the microscope in the shreds of 
mucus found in the stools. 

Remember that liver abscess is not a complication 
of bacillary dysentery. 

Remember that severe and painful joint symp- 
toms may be associated and lead to an erroneous 
idea of acute rheumatism. 

Remember that paralysis frequently follows bacil- 
lary dysentery. It is usually in the form of para- 
plegia. 



bacillary dysentery. 229 

Treatment. 

The patient should be confined to bed, as absolute 
rest is necessary in acute stage. When the pain is 
severe, a hypodermic of morphin should be given. 

Diet must be restricted to milk, whey, and broths. 
During an acute attack neither ice nor cold liquids 
should be swallowed, although the mouth may be 
rinsed with cold water to relieve thirst. In the 
severe cases peptonized milk should be given. Dur- 
ing convalescence great care must be exercised 
in the diet. Nutritious and easily digested food 
should be selected, and solid food should be with- 
held until all signs of enteritis have disappeared and 
the stools are normal. 

Medicinal. When seen early, a dram of mag- 
nesium or sodium sulphate every two hours until 
the stools are watery. The continuous administra- 
tion of the salines is the best form of treatment. 
The following give excellent satisfaction: 

B Solutionis magnesii sulphatis satu- 
rations 3 j 

Tincture opii, 

Acidi sulphurici aromatici aa 3 iv 

Essentia? pepsini (Fairchild) q. s. adSiij 
Misce. 
Big. : Teaspoonful every three hours. 



Or: 



IJ Cupri sulphatis gr. s 

Magnesii sulphatis 5 j 

Acidi sulphurici diluti 3 j 

Aquse menthse piperita . . . . q. s. ad 5 iv 

Misce. 

Sig. : Teaspoonful every four hours. 



230 INFECTIOUS DISEASES. 

Or: 

R Cupri arsenitis gr. % 

Tincturse opii camphorse 3 iv 

Essentia pepsini ( Fairchild ) q. s. ad % iij 
Misce. 
Sig. : Teaspoonful every three hours. 

Bichlorid of mercury in gr. M.oo-gr. % every two 
hours often gives excellent results. 

Bismuth is given frequently, but it is more effica- 
cious in the chronic form. When used, it should be 
given in massive doses, 3 ss-3 j, best given alone 
mixed with water. 

Ipecac in large doses is used extensively. No 
food is given for three hours, then 15 or 20 drops of 
the tincture of opium is given, and in half an hour 
3 ss-3 j of ipecac is given and the patient kept quiet 
on his back. Should it be vomited, it is repeated in 
one or two hours. After the acute symptoms sub- 
side, rectal irrigation should be begun. There are a 
number of astringents — such as alum, acetate of 
lead, sulphate of copper and zinc, and silver nitrate. 
Silver nitrate is best, and large quantities of the 
solution should be used, so that all parts of the 
colon will be thoroughly irrigated; 20 to 30 grains 
to the pint and 5 to 6 pints should be used at a 
time. The more chronic the condition, the better 
will be the result. 

Local Applications. Hot turpentine stupe or 
poultice will relieve pain and reduce the number of 
stools. 

Serum therapy is not at all satisfactory, and we 
must await further developments along this line. 



AMEBIC DYSENTERY. 231 

Amebic Dysentery. 

Remember that there are two forms — the acute 
and chronic — both caused by the ameba dysenteriae. 

Remember that the acute form is characterized 
by a sudden onset, with pain, tenesmus, and diar- 
rhea, the stools containing blood and mucus. 

Remember that, though the fever is not intense, 
there is rapid emaciation, and the patient may die 
in a week. 

Remember that hemorrhage of the bowel or per- 
foration, with peritonitis, may occur. 

Remember that leucocytosis occurs, and the count 
varies between 10,000 and 16,000. 

Remember that in the chronic form the onset is 
more insidious. 

Remember that in the chronic cases periods of 
attacks of pain, tenesmus, diarrhea, with mucus and 
blood in the stools and with slight fever, alternate 
with periods of constipation and apparent good 
health. 

Remember that these patients suffer from indi- 
gestion, and errors in diet cause a dysenteric attack. 

Remember that fatigue or sudden chilling of the 
body from exposure frequently produces an attack. 

Remember that the ameba coli is present in the 
stools, and should be sought for in suspected cases. 

Remember that it is in amebic dysentery that liver 
abscess is exceedingly common and should be 
watched for. 

Always outline the upper border of the liver daily, 



232 INFECTIOUS DISEASES. 

as the abscess is usually located near the upper sur- 
face and causes an irregular upward curve of 
hepatic dullness. 

Remember that other symptoms of liver abscess 
are fever, sweat, local pain, and edema. 

Remember these abscesses may rupture and drain 
through the lung. When this occurs, the sputum is 
dark and contains the ameba. 

Treatment. 

Rest in bed is very important in both forms of the 
disease, as it hastens recovery. 

Diet should be governed by the severity of the 
intestinal trouble. In the acute form it should be 
liquid, such as milk, whey, and broth. 

Intestinal antiseptics are used on the theory that 
ameba require the presence of other bacteria. 

Acetozone given by mouth and also in enema has 
accomplished some good. 

Bismuth in any form should not be given in 
amebic dysentery. 

That local treatment is best can not be disputed. 
Of all drugs used locally, quinin is best. The solu- 
tion of quinin should be 1:5000 at first, then in- 
creased to 1:2500, and later further increased in 
strength of 1:1000. 

If the following method of injection be followed, 
better results will be obtained: 

The patient should lie on his back, with the hips 
elevated, so that gravity will assist. From 1 to 2 



AMEBIC DYSENTEKY MEASLES. 233 

quarts of the solution should be used. The injec- 
tion should be given slowly, and the patient should 
turn from side to side during the injection, so 
that all parts of the colon will be bathed by 
the solution. The enema should be retained for 
fifteen or twenty minutes if possible. When the 
enema causes much pain, it may be preceded by in- 
jection of laudanum and starch water. Two injec- 
tions daily should be given. For the severe pain 
and tenesmus a hypodermic of morphin should be 
given. 

Large doses of ipecac are recommended by many, 
as are also saline injections and injections of ice 
water. 

Patients should not be allowed cold drinks during 
acute attacks, and hot applications to the abdomen 
often give great relief. 

Measles. 

Remember that the period of incubation varies 
between seven and fourteen days. 

Remember that the onset is usually with a coryza. 
The eyes are red and watery, and there is photo- 
phobia. 

Remember that the troublesome croupy cough be- 
gins early and continues throughout the course. 

Remember that there is fever on the first day, and 
that the peculiarity of the fever is its remission on 
the third. 

Remember that the eruption appears on the fourth 
day, beginning on the face. 



234 INFECTIOUS DISEASES. 

Remember that, as a rule, there will be patches of 
skin between the eruptions that will be of normal 
color, but the boundary between the eruption and 
the healthy skin is always crescent in shape. 

Remember that the eruption disappears on pres- 
sure, but in some cases hemorrhage, or petechia, 
occurs into the skin and they will not then disap- 
pear. 

Remember that, while there may be slight swell- 
ing of the cervical lymph glands at the height, it is 
never so pronounced as in scarlatina. 

Always look for Koplik's spots on the mucous 
membrane of the mouth. They occur, as a rule, on 
the first day of invasion, and consist of bluish- white 
specks surrounded by bright-red roseola. While 
they resemble that of thrush, they have not the 
yellowish center. 

Remember that the rash fades on the third day, 
and fine, branny desquamation occurs that is fre- 
quently overlooked. 

Remember that lobular pneumonia is exceedingly 
common, and usually occurs at the height of erup- 
tion or beginning of desquamation. Always ex- 
amine chest daily. 

Always look for otitis media, because it is com- 
mon in measles and may develop mastoid abscess. 

Never be in too great haste to differentiate 
measles and smallpox; it frequently requires some 
time for distinctive developments. 



MEASLES. 235 

Teeatment. 

The patient should be put to bed in a well- 
ventilated room. If photophobia be severe, the room 
should be darkened or yellow curtains hung. 

The diet should be liquid during febrile reaction. 
Milk and broths are best. Care in selecting a diet 
is necessary, that a troublesome diarrhea is not 
started. Cathartics should be used sparingly for 
the same reason. The best is castor oil with 2 or 3 
drops of turpentine in it. 

If the fever is high, sponging, or the warm bath 
gradually cooled, is excellent. 

Some simple fever mixture may be used, as : 

I£ Potassii citratis 3 iv 

Tincturse aconiti Tit x 

Spiritus aetheris nitrosi 3 ij 

Syrupi tolutani o j 

Aquae q. s. ad % ii j 

Misce. 

Sig. : Half to teaspoonful every two hours for child of 1 
to 2 years. 

Or: 

I£ Sodii bromidi gr. 1 

Spiritus aetheris nitrosi 3 ij 

Liquoris potassii acetatis . . q. s. ad 3 ii j 
Misce. 
Sig. : Teaspoonful every two hours for child of 1 to 3 years. 

The cough should be treated from the beginning 
of the attack. The fact should ever be kept in mind 
that tuberculosis very frequently follows measles. 

Paregoric may be added to either of the fever mix- 



236 INFECTIOUS DISEASES. 

tures. Codein is probably better. The following 
combination is very efficient: 

B Codeinae phosphatis gr. Ij 

Syrupi ipecacuanhas 3 j 

Syrupi pruni virginianse % j 

Aquae camphorae q. s. ad $ ii j 

Mi see. 

Sig. : Teaspoonful every two hours for child of 6 years; 
one-half to one-quarter the amount for younger child. 

Or: 

B Codeinse phosphatis gr. ij 

Ammonii carbonatis gr. xxx 

Syrupi scillae 3 j 

Syrupi pruni Virginians % j 

Aquae camphorae q. s. ad § iij 

Misce. 

Sig. : Teaspoonful every two hours for child of 6 years ; 
one-half to one-quarter the amount for younger child. 

Or: 

I£ Pellet aconitinae amorphae ( Abbott ) aa gr. % 34 
Sig. : Dissolve 1 for each year of child's age and 1 extra 
in 3 ounces of water and give teaspoonful hourly for fever. 

When the eruption fails to come out, wrap the 
child in blankets wrung out of hot water and give 
hot drinks. During convalescence the child should 
be given careful attention and protected from cold. 

Scarlet Fever (Scarlatina). 

Remember that the mild cases of angina may 
spread the disease. This is usually the way epi- 
demics spread in schools. 

Remember that milk is responsible for many epi- 
demics. 



SCARLET FEVER. 237 

Remember that a sudden onset, with vomiting and 
a rapid rise in the temperature, with a rapid, wiry 
pulse, is very characteristic of scarlatina in children. 
The next symptom in order of appearance and im- 
portance is the angina. 

Remember that the lymph glands behind the angle 
of the jaw are enlarged in scarlatina. 

Remember that the eruption comes early — usually 
by the second day — begins on the neck and chest, 
and spreads rapidly all over the body, with the ex- 
ception of certain parts of the face, especially the 
region of the mouth and chin, which are conspicuous 
by their pallor. 

Remember that there is a uniform blush of the 
skin, and the eruption is punctate and of a deeper 
color. There is no intervening healthy skin, and no 
crescentic arrangement of the eruption, as seen in 
measles. 

Remember that pressure causes blanching of the 
skin, but the blush quickly returns when pressure is 
removed. 

Remember that the tongue is very characteristic. 
On the first and second days the tip and margins 
are red, while the center is covered by a grayish- 
yellow coating. This coating disappears after the 
eruption is out, and the tongue now appears in- 
tensely red, with the papillae markedly swollen and 
raised, producing the "raspberry" or "strawberry" 
tongue, and this is very characteristic of scarlatina. 

Remember the following points in differentiating 
scarlatina and measles: 



238 INFECTIOUS DISEASES. 

1. The eruption of measles occurs first in the face, 
and is especially and markedly developed here, 
while in scarlet fever the neck and chest are first 
affected, and the face, nnder all circumstances, 
shows less eruption, and the region about the mouth 
is particularly free. 

2. The eruption of measles occurs on the fourth 
day, while in scarlet fever it may occur on the first 
and never later than the second. 

3. The onset of scarlet fever by vomiting and the 
severe angina, while the onset of measles is marked 
by inflammation of the mucosa of the respiratory 
tract — coryza. 

4. The drop in the temperature on the morning of 
the second day, with a subsequent rise on the third 
or fourth, is found only in measles. 

5. The " raspberry' ' tongue of scarlet fever is 
rather characteristic of it and is not seen in measles. 

Always examine the urine often from the ninth 
day until the sixth week for the appearance of signs 
of nephritis. This is the most common complication, 
but fortunately it rarely becomes chronic. 

Always watch the ears closely for otitis media, 
as it very frequently occurs in scarlatina, and, if 
neglected, will lead to mastoid disease. 

Remember that a polyarthritis often follows scar- 
latina, and may be diagnosed acute inflammatory 
rheumatism, but the ordinary rheumatic therapy 
will have no effect upon it. 



scarlet fever. 239 

Treatment. 

Prophylaxis. The patient should be isolated to 
prevent dissemination. As to the contagions 
periods, Forcheimer may be qnoted: "The disease 
is not contagions during the period of incubation; 
little, if at all, during the period of invasion; most 
contagious during the period of eruption, and de- 
cidedly so during the period of desquamation. ' ' 

The patient should be placed in a well-ventilated 
room, and be clad in light flannel gown and lightly 
covered. 

Diet must be liquid. Milk, broths, and fresh fruits. 
Water should be given freely. 

The throat and mouth should be washed thor- 
oughly with an antiseptic solution to protect the ear. 

The following is a good gargle: 

IJ Phenolis gr. xxx 

Glycerini 5 j 

Aquae camphorse 5 j 

Potassii chlorati gr. x 

Aquae q. s. ad 5 vj 

Misce et fiat solutio. 

Sig. : Use as a gargle two times daily. 



Or: 



Ifc Naphtolis 3 j 

Aquae camphorae 3 iv 

Glycerini § j 

Aquae rosae 5 ij 

Alcoholis 3 j 

Misce et fiat solutio. 

Sig.: Use as a gargle two times daily. 



240 INFECTIOUS DISEASES. 

Or: 

B Acidi borici 3 ss 

Potassii chlorati 3 ij 

Tincturse f erri chloridi 3 ij 

Syrupi simplicis 3 ij 

Aqua? q. s. ad § iv 

Misce. 

Sig. : Tablespoonful every two hours for child of 5 years. 

The pharynx and posterior nares may be sprayed 
with an atomizer, nsing chloretone inhalant (P. D. 
& Co.), or 5 grains of menthol to 1 ounce of aboline. 
Peroxid of hydrogen may be used, either pure or 
combined with glycerin. Careful attention to the 
nose and throat often prevents ear complications. 

"When diphtheritic patches occur, they should be 
wiped off with a swab and Loffler's solution applied. 
This solution consists of: 

B Mentholis 3 iiss 

Toluolis I j 

Liquoris f erri chloridi 3 j 

or creolin lU, yyy 

Aleoholis absoluti § ij 

Misce et fiat misturse. Dispense in brown bottle. 
Sig. : ' Use as a gargle and swab the throat thoroughly. 

Fever is best combated by hydrotherapy. The 
cold bath of typhoid should not be used. In light 
cases, sponging with cool water or water and vine- 
gar, with cold applied to the head, either as ice bag 
or towel wrung out of ice water. Where the tem- 
perature runs high, the patient may be put in tepid 
bath and the temperature gradually reduced, but 
never below 75° F. 



SCARLET FEVER. 241 

Aconite, either as the tincture ttl j-iu ij every 
hour, or the active principle aconitin amorphous 
gr. %34 every fifteen to thirty minutes, may be given 
to child of 5 years until effect, and then continued 
hourly. The following is a good fever mixture: 

IJ Liquoris ammonii acetatis 3 vj 

Potassii chlorati 3 ss 

Tincturse aconiti TTL xxx 

Syrupi limonis 3 v 

Aquse q. s. ad g iij 

Misce et fiat solutio. 

Sig. : Teaspoonful every two hours, and may be given 
hourly if temperature be high. 

Quinin and phenacetin are very effective and bene- 
ficial in many ways. 

IJ Euquinini ( Merck ) gr. xxx 

Phenacetini gr v 

Syrupi pruni virginianas 5 v j 

Aquse menthae piperita^ .... q. s. ad § ij 
Misce et fiat misturse. 

Sig.: Teaspoonful every two or three hours^ as indicated, 
for child of 2 to 10 years. 

Delirium and muscular twitching call for sodium 
bromid. Usually ice pack to the head is sufficient, 
as the cerebral congestion from the fever causes 
delirium. 

Cardiac failure calls for stimulants. The follow- 
ing is very efficient : 

IJ Camphorse 3 ss 

Aetheris 3 v 

Misce. 

Sig.: Inject 20 minims subcutaneously. 

Whisky, brandy, or aromatic spirits of ammonia 
may be used. 



242 INFECTIOUS DISEASES. 

Delayed eruption is best treated with atropin 
gr. %5o every hour until physiologic effect. Warm 
baths will assist also in bringing out the eruption. 

Calcium sulphid and urotropin should be given 
throughout the disease. 

Calcium sulphid gr. j-gr. ij should be given when 
the stomach is empty to prevent the action of HC1. 

Urotropin gr. %-gr. v, according to age, is given 
three times daily, as its antiseptic action on the 
urine is thought to protect the kidneys. 

Tincture of iodin, glycerin, and ichthyol, equal 
parts, painted over the enlarged tender glands of 
the neck and covered by rubber tissue, will prevent 
suppuration in many cases. Unguentum Crede may 
also be used, or unguentum hydrargyri ammoniati. 
When fluctuation can be detected, the gland should 
be opened and drained. 

Nephritis. As a preventive measure to a certain 
degree, the following gives good results, probably 
because it quiets the nervous system: 

B Chloral hydratis 3 ij 

Sodii bromidi 3 iij 

Syrupi tolutani 3 j 

Aquae q. s. ad t iij 

Misce. 

Sig. : Teaspoonful every two or three hours. 

Plenty of water and a milk diet are excellent pro- 
phylactic measure. 

The urine should be examined daily for albumin. 
When nephritis develops, the treatment in no way 
varies from that outlined under acute nephritis. 



SCARLET FEVER MALARIA. 243 

During the period of eruption and desquamation the 
body should be rubbed daily with some oily sub- 
stance, as carbolated vaselin or plain olive oil, or 
where there is much itching the following: 

Ifc Mentholis gr. xx 

Olei olivse 3 i j 

Adipis lanae 3 i j 

Misce et fiat unguentum. 

Sig. : Anoint body one or two times daily. 

A warm bath should be given daily to hasten the 
desquamation. The body should be thoroughly 
rubbed during the bath and dried with a tolerably 
rough towel, and some ointment applied. This pre- 
vents the scales from flying and lessens the danger 
of spreading the disease. 

Convalescence calls for tonics, especially those 
containing iron. There is none better than elixir 
of iron, quinin, and strychnin, and essence of pepsin, 
equal parts, and give a teaspoonful three times daily. 

Malaria. 

Remember that the disease is communicated to 
the well solely by the mosquito; hence the impor- 
tance of insisting upon a malarial patient being pro- 
tected from the mosquito. 

Remember that the disease may remain dormant 
for a variable time and again produce the clinical 
symptoms. This is likely to be thought a reinfec- 
tion, when it is an old infection that has not been 
sufficiently treated to be cured. There are a number 
of types: 



244 INFECTIOUS DISEASES. 

1. Intermittent Fever. 

Remember that this is the common fever and ague, 
and is characterized by chill, fever, and sweat, fol- 
lowed by a total remission of fever. 

Remember that the chill may be light or severe, 
and begins gradually. The temperature rises during 
the chill. 

Remember that the chill may be overlooked, espe- 
cially in young children, but the lips are blue, the 
face is pale and pinched, the skin feels cold, and 
there is vomiting. In children the fever may cause 
nervous symptoms that may mislead in diagnosis. 

Remember that the pulse is small, hard, and fre- 
quent; the hands are cold, and the finger nails are 
blue. 

Remember that fever follows the chill, but that 
the temperature begins to rise even prior to the 
chill and usually reaches its maximum at the end 
of the chill or very soon thereafter. This is the 
period of circulatory reaction of the superficial ves- 
sels, and the skin becomes red, hot, and dry. Thirst 
is intense, and a throbbing headache announces the 
dilatation of the cerebral vessels. 

Remember that the sweating stage is the last in 
the paroxysm, and affords relief of all the symp- 
toms. The amount of sweating varies from a moist 
skin to a profuse, drenching the clothes and bed. 

Remember that the duration of the paroxysm va- 
ries from eight to twelve hours, and during the 
paroxysm the spleen is enlarged. 



MALARIA. 245 

Remember that herpes labialis occurs more fre- 
quently in malaria than in any other condition, and 
is very suggestive when it occurs. 

Remember that there are other conditions caus- 
ing chills, fever, and sweat. The two most common 
are tuberculosis of the lungs and pyemia. 

Remember that the paroxysms of chill, fever, and 
sweat found in malaria are periodical, occurring 
with marked regularity, while the paroxysms occur- 
ring in the other infections are irregular, sometimes 
occurring daily and then less frequently. 

Remember that the blood examination will show 
the Plasmodium in malaria, while a blood culture 
will give a growth of streptococci in septic cases. 

Remember that in the nervous chill there is no 
fever, or at most the rise will be very little, while 
the other phenomena of malaria will be absent. 

2. Remittent Fever. 

This is also called the estivo-autumnal fever, but 
is probably best known as bilious fever. 

Remember that the prodromal symptoms are pro- 
nounced and misleading. They are malaise, intense 
headache, coated tongue, and frequently nausea and 
vomiting. The vomiting may be of bilious matter, 
and there may be jaundice, with tenderness on pres- 
sure over the liver. 

Remember that the chill is less severe and lacks 
the characteristic periodicity of intermittent. 

Remember that the temperature is continually 
above normal, but there are remissions in the height. 



246 INFECTIOUS DISEASES. 

Remember that the blood examination shows the 
small, active, motile, hyaline form of the plasmodia, 
while later the crescentic, ovoid bodies may be 
found. 

Remember that malarial infection of any type 
will yield when the patient is cinchonized, bnt don't 
forget that there is a difference between giving 
quinin and cinchonizing a patient. 

Remember that typhoid and remittent malarial 
fever is frequently confused, but the following 
should determine the question: 

1. Plasmodium found in the blood in malaria. 

2. Eruption in first week in typhoid fever. 

3. Widal reaction of agglutination present in ty- 
phoid and occurring from the fifth day on. 

4. Cinchonizing patient with quinin will send the 
temperature to normal in malaria; no effect in 
typhoid. 

3. Pernicious Malaria. 

Remember that the pernicious types may not be- 
gin with a chill and the onset may be sudden. 

Remember that there are two types — comatose 
and algid. In the comatose type there are low, mut- 
tering delirium, skin is hot and dry, temperature 
high, and may terminate fatally. The digestive sys- 
tem bears the brunt of the attack in the algid type. 
There are extreme nausea, vomiting, collapse, with 
coldness of the extremities. The pulse becomes 
small and feeble, the breathing is rapid and shallow, 



MALARIA. 247 

suppressed urine, colicky pains, purging, and great 
thirst. 

Remember that the pernicious forms may be com- 
plicated by paraplegia, and acute ataxia has been 
described. Multiple gangrene may occur. Orchitis 
has occurred in some cases. 

4. Chronic Malaria. 

The cachexia is the most prominent symptom. 
It is caused by blood changes. Anemia is extreme, 
and causes breathlessness on exertion; edema of 
the ankles. The spleen is enlarged and hard; its 
border may extend to the iliac crest. Some cases 
are jaundiced, and all have a peculiar yellow color. 

Eemember that leukemia causes an enlarged 
spleen, but the changes in the blood cells are very 
characteristic in leukemia, and, in addition, the Plas- 
modium is found in the blood in malaria. 

Remember that intense choleraic form occurs. 
The purging is very profuse and watery. There is 
fever and collapse, and death may occur. 

Remember that there is a gastralgic form, in 
which there is agonizing epigastric pain, abdominal 
tenderness, and perhaps diarrhea. It has been mis- 
taken for appendicitis by surgeons. 

Remember that malaria may closely simulate 
dysentery. There will be frequent, mucoid, bloody 
stools; colicky, abdominal pains; tenesmus, and pro- 
gressive emaciation. 

Remember that neuralgia may be of malarial 



248 INFECTIOUS DISEASES. 

origin. The proper administration of quinin is usu- 
ally very efficacious in these cases. 

Eemember that hematuria may occur in any ma- 
larial infection, but is much more common in the 
tropics. This is a hemoglobinuria, and the parasite 
can always be found in the blood. It is doubtful as 
to quinin either causing it or making it worse. 

Treatment. 

Patients known to be malarial should be protected 
from mosquitoes, so that the infection may be lim- 
ited. 

Calomel as a cathartic has no equal in beginning 
the treatment. 

Vomiting should be controlled by calomel and 
cerium oxalate. 

Quinin is the specific for malaria, but its action 
can be enhanced by proper combinations. 

There is a vast difference between stopping the 
paroxysms of malaria and a cure. 

The mixed treatment is the best. The following 
has given excellent results in a large number of 
cases: 

IJ Codeinae pliosphatis gr. % 

Quininae hydrochloridi gr. iij 

Arseni trioxidi gr. y so 

Ferri f errocyanidi gr. j 

Pulveris camphorae gr. j 

Misce et fiat capsula No. I. Dentur tales doses No. XX. 

Sig. : Capsule every three hours. 

This is given after a good purge with calomel. 



MALARIA. 249 

For children and those unable to take a capsule the 
following is good: 

B Euquinini (Merck) 3 j 

Syrupi pruni virginianae 3 vj-3 viij 

Rub up the euquinini thoroughly with syrup. 

Codeinse phosphatis gr. iss-gr. ii j 

Liquoris potassii arsenatis Tit lx-IT}, lxx 

Aqua? menthae piperita* .... q. s. ad 5 ii j 

Misce et fiat misturse. 

Sig. : Teaspoonful every three hours. Shake. 

For the pernicious forms quinin must be given 
hypodermatically. 

I£ QuininsB hydrochloridi gr. xxx 

Antipyrini gr. xx 

Aqua? destillatse 3 j 

Misee et fiat solutio. 

Sig.: Inject 10 minims every three or four hours. 

Quinin hydrobromid, in 3-grain doses, dissolved 
in 20 minims of pure warm water and sterilized, 
makes probably the best method of administering 
quinin hypodermatically. In injection of solution 
of any of the salts of quinin it should be made deep 
into the muscle. 

Where a solution of quinin is to be given per os, 
the following affords a good example. Never use 
any flavoring syrup, as it keeps the bitter taste in 
the mouth, while a good drink of water in a plain 
solution removes all the bitterness. 

I£ Quininse hydrochloridi 9 iv 

Tincturse ferri chloridi 3 iv 

Aquse q. s. ad 3 iij 

Misce. 

Sig.: Teaspoonful every three hours. 



250 INFECTIOUS DISEASES. 

Where there exists an idiosyncrasy against quinin 
other drugs must be used. 

I£ Methylene blue © ij 

Arseni trioxidi gr. ss-gr. j 

Pulveris myristicse 3 ij 

Misce et fiant capsular No. XX. 

Sig. : Capsule four times daily. 

Or: 

IJ Tincturse eucalypti § j 

Sodii arsenatis gr. 3^ 

Acacise, 

Aquae gaultherise aa q. s. ad 3 ij 

Misce et fiat emulsio. 

Sig.: Teaspoonful every two or three hours. 

The treatment of malaria should be continued for 
at least two weeks after the subsidence of all symp- 
toms if the plasmodia are to be completely eradi- 
cated. The amount of quinin given should be re- 
duced. Three grains three times daily are sufficient, 
but must be given so that it will be absorbed — best 
in capsule, followed by acid drink, as lemonade or 
dilute muriatic acid. During this period of conva- 
lescence iron should be given, and Blaud's pill can 
not be improved upon. Ferri carbonatis may be 
given in the quinin capsule. 

In chronic malaria, with the enlarged hard spleen, 
potassium iodid should be used and Fowler 's solu- 
tion should be pushed. In administering Fowler's 
solution, it is better to begin with a small dose — 
2 minims — three times daily after meals and in- 
crease 1 minim every third day until puffy eye-lids 
or diarrhea announce complete saturation, when the 



MALARIA — DIPHTHERIA. 251 

dose should be reduced by dropping 1 minim every 
third day until 2 minims are taken at a dose. 

Diphtheria. 

Remember that it is highly contagious, either di- 
rectly from sick to well or through some intervening 
body, as nurse, physician, or articles about the pa- 
tient. 

Remember that we have diphtheria carriers, as in 
typhoid. They show no signs of infection, yet the 
germ has been obtained from their throats. 

Remember that milk is responsible for many epi- 
demics, the teats of the cow harboring a virulent 
organism. 

Remember that children from 2 to 5 years are 
most susceptible. 

Remember that not all cases that have a mem- 
brane in the throat have diphtheria. The strepto- 
cocci often cause a diphtheroid condition of the 
throat, but the clinical symptoms are not character- 
istic of true diphtheria. 

Remember that in the laryngeal form the child is 
usually hoarse at night and has a brassy, croupy 
cough. 

Remember that dyspnea, becoming extreme as the 
membrane advances until eventually cyanosis and 
carbonic acid poisoning, is the course of diphtheritic 
croup. 

Remember that otitis media is frequent in diph- 
theria, and in the nasal form the eyes may become 
involved. 



252 INFECTIOUS DISEASES. 

Remember that a serous, sanguinous, or bloody 
discharge from the nose that excoriates the mucosa 
and the skin is very suspicious of diphtheria. 

Remember that paralysis of the soft palate and 
the regurgitation of liquids through the nose is very 
characteristic of diphtheria. 

Always make a bacterial examination of the 
throat, as the presence of Klebs-Loffler bacilli makes 
it diphtheria, regardless of the presence or absence 
of a false membrane or other clinical signs. 

Remember that the systemic reaction caused by 
the local infection produces fatigue, drowsiness, pal- 
lor, coated tongue, anorexia, dysphagia, and vomit- 
ing. There may be a chill, but more often chilliness, 
and the temperature usually rises gradually until 
it reaches 102° or 103° F., remains stationary a 
couple or three days, then declines by lysis, and rises 
again from the fourth to the seventh day. The 
pharynx is red, edematous, and glistening. A gray- 
ish-white membrane, changing later to a dirty-gray, 
may be seen on the tonsils, fauces, or posterior wall 
of the pharynx. 

Remember that the peculiarities of the membrane 
are its gradual growth until it covers the tonsils, 
faucial pillars, uvula, and palate; and, further, that 
it is firmly adherent, so that when removed a raw, 
bleeding surface is left, which is again soon covered 
by a membrane. The voice has a " nasal twang.' ' 

Remember that the lymph glands at the angles of 
the jaw are enlarged and may be tender. 



DIPHTHERIA. 253 

Remember that the membrane may be absent, and 
nothing more than catarrhal condition of the throat 
be present on inspection and the patient have a 
cronpy cough. 

Remember that in some cases the tonsils are cov- 
ered by an exudate closely resembling that seen in 
follicular tonsillitis, and no true membrane be 
present. 

Remember that there are cases in which the tox- 
emia is so profound that the patient succumbs be- 
fore local lesions occur. 

Remember that when bacteriologic examination 
can not be made, all cases of "sore throat" and 
croup, especially if there is swelling of the lymph 
glands at the angles of the jaw, must be regarded 
as diphtheria. 

Treatment. 

Hygienic. Confine patient to a room free of car- 
pet, curtains, and superfluous furniture. Keep the 
room temperature at 68° F. and air moistened by 
kettle. Good ventilation must be secured. No one 
but the nurse and the doctor in the room. All bed 
clothes and whatever is used about the patient 
should be immediately thrown into a solution of 
carbolic acid. 

Local treatment consists of swabbing, spraying, 
and gargle — peroxid of hydrogen full strength, car- 
bolic acid 1 to 3-percent solution, bichlorid of mer- 
cury 1:5000. 

A very excellent method is the application of 95- 



254 ESTECTIOUS DISEASES. 

percent phenol by swab to the area covered by the 
membrane, and repeat once daily, making a thor- 
ough application. 

In laryngeal croup a steam tent may be arranged 
upon the bed, so that the air breathed by the child 
will be saturated with moisture. When signs of 
obstruction are marked, intubation or tracheotomy 
should be performed. 

Hot applications should be applied to the neck of 
children, while cold should be used in adults. 

Diet should be liquid — milk, soups, and broths. 
Albumen water and plain water should be used 
freely. The bowels must be kept open, and calomel 
in fractional doses is best. 

Sponging may be used to reduce the fever when 
the temperature is high. 

Stimulants should be used when indicated. It 
should never be forgotten that the toxin has a se- 
lective cardiac action, and the heart must be closely 
watched. 

The patient should be kept in bed and quiet, and 
all excitement avoided. Atropin sulphate gr. %oo- 
gr. Yqo, adult dose, administered hypodermatically 
should be used at the first sign of heart weakening. 
Inasmuch as the toxins are retained in the body 
some time after the recovery, the child should be 
kept in bed two weeks after normal temperature 
has been established. 

Specific treatment is the only sane and rational 
way to treat. Antitoxin should be administered 



DIPHTHERIA RHEUMATIC FEVER. 255 

early and in sufficient doses. The earlier the anti- 
toxin is given, the less likely to have complications, 
and especially of the heart. One should make it a 
rule to give it in cases that are at all suspicious. 
Dose enough is a hard question to decide, because 
the dosage is empirical. Administer 4,000 or 5,000 
units, and repeat in twenty-four hours if no signs 
of the membrane loosening at the border and the 
symptoms do not improve. Antitoxin is harmless, 
and should be given until results are obtained. 

Rheumatic Fever (Inflammatory Rheumatism). 

Remember that this is an acute infectious disease, 
due to a micro-organism not yet isolated. 

Remember that exposure to cold and wet is more 
important as a cause than heredity. 

Remember the close relationship that exists be- 
tween inflammatory rheumatism and tonsillitis, and 
frequently an apparent tonsillitis is but the onset of 
rheumatism. 

Remember that the onset is usually sudden, with 
rigor or chill and a rise of temperature. The pulse 
is soft and frequent, usually above 100. 

Remember the profuse acid sweat, with a peculiar 
sour odor. 

Remember that the joints soon become red, swol- 
len, and exquisitely painful. The peculiarity of the 
joint involvement of skipping from joint to joint is 
characteristic of inflammatory rheumatism. 

Remember the anemia. No other acute febrile 



256 INFECTIOUS DISEASES. 

disease causes such a rapid anemia, which accounts 
for the pallor. 

Remember that the joint involvement is rare in 
children, and cardiac complication exceedingly 
common. 

The "growing pains" of childhood are rheuma- 
tism, and should be carefully looked after. 

Remember that arthritis occurring in septico- 
pyemia is fixed, and few joints involved. The fever 
is more distinctly intermittent. 

Remember that in acute osteomyelitis the epiphy- 
sis is the seat of the trouble, and the joint is not in- 
volved, while the local and constitutional symptoms 
are more severe. 

Remember that gonorrheal arthritis is not migra- 
tory. The joints involved are more apt to be the 
knee, sternoclavicular, or vertebral joints, and the 
urethral discharge of the male or vaginal discharge 
of the female should be examined for the gonococci. 

Remember that an arthritis deformans may be- 
gin with an acute inflammation of joints and fever. 
It is usually the smaller joints that are involved, 
but in many cases it will require time to differen- 
tiate. When the acute symptoms pass in arthritis 
deformans we find joint changes with periarticular 
thickening, while in inflammatory rheumatism there 
are no permanent joint changes. 

Remember that acute rheumatism attacking the 
joints of the spine may closely simulate meningitis, 
but the severe headache, pupillary changes, hyper- 
esthesia, and Kernig's sign are absent. 



RHEUMATIC FEVER. 257 

Remember that during the course of acute rheu- 
matic fever, cerebral rheumatism may develop, 
marked by rapid rise of temperature — 106° to 108° 
F. — rapid small pulse, nystagmus, vomiting, spastic 
paralysis, strabismus, and wild delirium. This is a 
very serious condition, which may terminate fatally. 

Treatment. 

The patient should be dressed in light flannel 
gown, and confined to his bed between blankets. 
The inflamed joints should be wrapped with cotton 
and bandaged. 

Diet should be liquid and light. Milk is best, and 
to it should be added a little bicarbonate of soda. 
Broths may be used, also farinaceous foods, but 
meat should not be allowed. Lemonade should be 
freely given. 

Hyperpyrexia must receive prompt and vigorous 
treatment to save life — the cold bath or cold applied 
along spine by rubbing with a piece of ice. When 
the temperature is reduced, there is great likelihood 
of its rising again. Pain may be so severe as to 
require hypodermic of morphin. Codein gr. % hourly 
usually gives relief. 

Sodium salicylate for the cure of inflammatory 
rheumatism is almost universally used. Salicylic 
acid is often used, but its irritating effect upon the 
stomach has lessened its general use. Strontium 
salicylate is used and highly recommended. All 
these salts should be given in 10 to 15-grain doses, 



258 INFECTIOUS DISEASES. 

and for the first twenty-four to forty-eight hours 
should be repeated often enough so that from 1 dram 
to V/2 drams are taken in twenty-four hours. The 
important thing is not the quantity, but the complete 
saturation of the patient, which is manifested by 
buzzing in the ears. The drug should then be re- 
duced by lengthening the interval. An alkali should 
be combined with the salicylate treatment — either 
sodium or potassium bicarbonate, or potassium 
citrate. The following have given good service: 

Ifc Sodii salicylates 3 v 

Potassii bicarbonatis 3 iiss 

Vini colchici 3 iij 

Aquae menthae piperitae q. s. ad 3 iv 

Misce. 

Sig. : Teaspoonful every two hours for two days, then 
every three hours. 

Or: 

I£ Acidi salicylatis, 

Potassii acetatis aa 3 iss 

Antipyrini 9 ij 

Syrupi simplicis 3 iss 

Aquae bullientis 3 vj 

Misce. 

Sig.: Tablespoonful every three hours. 

Or: 

Ifc Antipyrini gr. xx 

Sodii salicylatis 3 ij 

Syrupi sarsaparillse compositae 3 ii j 

Aquae menthae piperitae . . . . q. s. ad 5 vj 
Misce. 
Sig.: Tablespoonful every three hours. 

Or: 

IJ Asperini 3 i j 

Fiant capsulae No. XII. 

Sig.: Capsule every two or three hours. 



RHEUMATIC FEVER. 259 

The following is the best for local application, as 
it gives prompt relief: 

IJ Magnesii sulpliatis 3 i j 

Phenolis 3 j 

Aquae bullientis O j 

Misce. 

Sig. : Envelop the joint with, cotton lightly squeezed out 
of this solution, cover with dry cotton, and apply roller 
bandage lightly. 

It is essential that the salicylates be kept up in 
smaller doses for some time after temperature is 
normal to prevent relapse. 

Convalescence. The administration of iron for 
anemia — the elixir of iron, quinin, and strychnin 
(U.S. P.)— is excellent. 



CHAPTER XII. 

CONSTITUTIONAL DISEASES. 

Arthritis Deformans. 

Remember that this is an affection in which pro- 
found changes occur in the joint, and these changes 
are not only chronic, but progressive. 

Remember that in this condition there is no uni- 
formity in the mode of onset. Some cases have an 
acute onset, with fever; red, swollen, and tender 
joints, so closely resembling acute rheumatism that 
a positive diagnosis will be impossible during this 
stage. 

Remember that in acute rheumatism the tendency 
is to a complete restoration of the joint function, 
while in arthritis deformans the tendency is always 
toward joint destruction, and each attack further 
impairs the action of the joint. 

Remember that the small joints of the hand and 
feet are the first to be attacked. 

Remember that in an acute attack, pain, limita- 
tion of movement, and swelling of the joints are 
present. The intensity of the pain is of no aid in 
prognosis. First, the characteristic of the pain is 
that it is spontaneous, coming when the joints are 
at complete rest; often made worse by the warmth 
of the bed. Second, it is not shifting like that seen 
in rheumatic fever. Third, muscular cramp, due 

260 



ARTHRITIS DEFORMANS. 261 

to the spasmotic contraction of the atrophied mus- 
cles, thus increasing tension and pressure on the 
inflamed joint. 

Remember that swelling is a very early manifes- 
tation of the disease. The swelling is fusiform, due 
to the thickening of the capsule of the joint. The 
atrophy of the intervening muscles causes the fusi- 
form appearance of the joints to be more pro- 
nounced. The large as well as the small joints show 
this fusiform appearance. 

Remember that muscular atrophy occurs in all 
cases, and is marked by its progressiveness, advanc- 
ing pari passu with the joint lesion. 

Remember that in many cases the axillary and in- 
guinal glands are swollen. 

Remember that the pigmentation of the skin is a 
prominent sign in many cases. It occurs on the fore- 
head, temples, face, and neck. The tints vary, but 
the most common are lemon, orange, or citron color. 
The patches have a luster varying with the angle 
of reflected light. 

Remember that a rapid pulse, having no relation 
to the fever, is of considerable value in diagnosis. 

Remember that the symmetry of joints involved is 
very significant, while the large number of joints 
involved and the absence of any tendency to casea- 
tion exclude tuberculosis in the diagnosis. 

Remember that Heberden's nodes, when present, 
are found on the sides and ends of the distal 
phalanges, especially of the fingers, but sometimes 



262 CONSTITUTIONAL DISEASES. 

of the toes. When found, they are of prognostic 
value, as the large joints very rarely become in- 
volved, and these nodosities are said to be promises 
of long life. 

Remember that joint distortion is characteristic, 
and due to exostoses or outgrowths of bony sub- 
stances that lock the joint. 

Treatment. 

Rest during an acute attack is imperative, and, 
owing to rheumatic simulation at this stage, the 
salicylates should be given. 

Massage should not be attempted with an acutely 
inflamed joint, but it is clearly indicated after this 
subsides. When carefully and perseveringly carried 
out, it is beneficial. 

Diet. Plenty of good, nourishing diet should be 
given. There is not an article of diet that is known 
to aggravate it. 

Baths. Hot baths are excellent and a course at 
Hot Springs, Arkansas or Virginia, will often be 
very beneficial. 

Medicinal. Fowler's solution of arsenic, given 
in 3 to 5-drop doses, has given good results in some 
cases. Guaiacol carbonate gr. v-gr. xv daily and 
rapidly increased gives good results, and its good 
effect, as well as that of arsenic, appears to be en- 
hanced if an iodid be combined. The iodid of iron 
may be given, or a saturated solution of sodium 
iodid, 10 to 15 drops in milk, an hour after meals. 



ARTHRITIS DEFORMANS GOUT. 263 

Superheated air to the affected joints by means of a 
hot-air apparatus gives good results in many cases. 

Gout. 

Remember that gout is a nutritional disorder, and 
the arthritis is due to the deposit of sodium biurate 
from the blood, which is surcharged with an excess 
of uric acid. 

Remember that the use of fermented liquors and 
little exercise is responsible for a large majority of 
the cases. 

Remember that gout and arteriosclerosis usually 
coexist. 

Remember that the following are the premonitory 
signs of an attack of acute gout : twinges of pain in 
the small joints of the hands or feet, restlessness at 
night, irritability of temper, and dyspepsia, with 
scant, highly colored and acid urine that deposits 
urates on cooling. 

Remember that the announcement of the onset is 
by severe, vise-like pain, occurring in the metatarso- 
phalangeal articulation of the big toe — most com- 
monly the right. The attack is usually nocturnal, 
gradually subsiding with approach of day. The 
joint swells rapidly, the tissues become edematous, 
and the skin is hot, tense, and shiny. Fever is 
present. 

Remember that the subsidence of the attack by 
morning, to recur again on the succeeding night, is 
markedly characteristic of acute gout. 



264 CONSTITUTIONAL DISEASES. 

Eemember that, notwithstanding the swollen, 
edematous condition of the joint, it never goes on 
to suppuration, but gradually subsides and the skin 
desquamates. 

Remember that the deposit increases with each 
succeeding attack until the joint is swollen, irregu- 
lar, and deformed. 

Remember that the urates are deposited in the 
cartilages of the ears, along the tendons, and in the 
bursa?, and may be felt as tophi in the ears. 

Remember that severe cramps in the muscles of 
the calf, abdomen, or thoracic regions occur in the 
chronic form. 

Remember that in gouty subjects severe gastro- 
intestinal catarrh, with pain and diarrhea, migraine, 
sciatica, and various other neuralgias, often take 
the place of the ordinary acute type. 

Burning sensation and itching of the feet at night, 
and skin lesions, such as eczema, is a frequent com- 
plaint of patients with gouty diathesis. 

Remember that the family history and occupa- 
tion are exceedingly important factors in arriving 
at a diagnosis. 

Remember that there is a moderate leucocytosis 
during an acute attack of gout. 

Remember that there are some conditions closely 
allied to gout, but are classed as lithemia. There 
are various symptoms grouped under this heading, 
as indigestion, vertigo, headache, nervous irritabil- 
ity, tingling and a sense of numbness, and a slow 



gout. 265 

pulse, with increased tension and a sharp accentua- 
tion of the aortic second sound. 

Treatment. 

Acute Attack. The first thing to be done is to re- 
lieve the pain. The extremes of temperature — cold 
and hot — should never be applied; necrosis is 
thus encouraged. The joint should be kept quiet 
and wrapped in cotton or compress wrung out of 
water at the room temperature, or gauze out of the 
following solutions may be applied: equal parts of 
chlorof om and olive oil, or oil of gaultheria, to which 
may be added the tincture of opium in the ratio of 
1 to 10. The following is good: 

Ifc Tincturae opii 3 v 

Olei gaultherise 5 j 

Chlorof ormi 3 iss 

Misce et fiat solutio. 

Sig. : Paint the joint several times daily. Shake well. 

Or: 

I£ Extracti belladonnae gr. xlv 

Extracti opii gr. v-gr. xv 

Unguenti ichthyolis, 10-percent. ...^ j 

Misce et fiat unguentum. 

Sig.: Apply two times daily. 

Or gauze out of a saturated solution of Epsom 
salts applied locally. 

Medication. Colchicum appears to be the favor- 
ite, but should be administered cautiously, and 
should not be continued indefinitely. The active 
principle, colchicin gr. M.oo-gr. % , combined with 
codein phosphate gr. %, administered every one or 



266 CONSTITUTIONAL DISEASES. 

two hours until diarrhea, nausea, etc. — the symp- 
toms of poisoning — when it should be administered 
less frequently, is excellent. The bowels should be 
opened freely with saline laxative. Potassium iodid 
in stubborn cases is good. 

B Potassii iodidi gr. lxxv 

Tincturae coleliici 3 iiss 

Aquae destillatae § v 

Sig. : Tablespoonful in glass of water after meals. 

Sodium salicylate is preferred by many in 15-grain 
doses four times daily to adult man. 

For the uric acid condition, as well as chronic 
gout, that medication which will assist in holding 
urates in solution is the best. The disodium phos- 
phate appears to be the important element in dis- 
solving urates, and the administration of calcium 
salt, preferably the carbonate, protects this sodic 
phosphate and thus assists in the solution of the 
urates. This may be prescribed as follows: 

I£ Calcii carbonatis gr. x 

Lithii carbonatis gr. j 

Colchicini gr. i{ 00 

Pnlveris aromaticae gr. x 

Misee et fiat pulvere No. I. Dentur tales doses No. L. 

Sig.: Powder every three hours in acute conditions; three 
times daily in chronic or lithemic conditions. 

These patients must drink plenty of water, 
whether it be acute or chronic condition. The alka- 
line mineral waters are best. 

Exercise must be taken, even in acute cases, just 
as soon as they are able to be up. 

Diet. Most of these patients eat too much. The 



GOUT DIABETES MELLITUS. 267 

amount of food should be reduced. Plenty of fresh 
vegetables and fruits should be taken. Meats are 
allowable. Fats and carbohydrates should form a 
large part of the diet, especially the fats. 

Lithemic patients should be given potassium iodid 
at intervals to assist in elimination. 

Diabetes Mellitus. 

Remember that not all cases which show sugar in 
the urine* are diabetics. The following three factors 
must be true in all cases of diabetes: 

1. The form of sugar in the urine must be grape 
sugar. 

2. It must be found for a long period of time — for 
weeks, months, or even years. 

3. The excretion of sugar must take place after 
the ingestion of a moderate amount of carbohy- 
drates. 

Remember that a slight trace of sugar is common 
in obese persons. 

Remember that the two important etiologic fac- 
tors that produce diabetes are: 

1. Pronounced nervous derangement; either func- 
tional — as worry, mental shock, or some severe ner- 
vous strain; or organic lesion — as disease of the 
spinal cord or brain, or injury in the region of the 
floor of the fourth ventricle. 

2. Disease of the pancreas, leading to the destruc- 
tion of the cells of the islands of Langerhans — most 
frequently caused by chronic pancreatitis, and it is 



268 CONSTITUTIONAL DISEASES. 

through this condition that gallstones become an 
etiologic factor. 
Remember that urinalysis reveals: 

1. Large increase in the amount of urine for 
twenty-four hours. 

2. High specific gravity. 

3. Pale color and sweetish odor. 

4. Acid reaction. 

5. Sugar is present. 

6. Albumin usually. 

Remember the diabetic tabes — a peripheral neuri- 
tis, with lightning pains in the legs and loss of knee- 
jerk. The patient has the " steppage gait" seen in 
arsenical and alcoholic neuritic paralysis. 

Remember that a patient complaining of exces- 
sive thirst, inordinate appetite, and frequent mictu- 
rition calls for an examination of the urine for 
sugar. 

Remember that the tongue is dry, glazed, and red, 
and the mouth is dry. The gums are swollen, and 
constipation is the rule. The skin is dry, no sweat- 
ing unless coexisting phthisis be present, furuncu- 
losis is common, and general pruritus may be very 
distressing. 

Remember the coma that develops in these cases, 
due probably to acetone, and usually terminates 
fatally. 

Remember that fraud is often practiced, and cane 
sugar has been found in the urine. 

Remember that gangrene may occur, due to 
arteriosclerosis. 



DIABETES MELLITUS. 269 



Treatment. 



Diet. The first thing is to determine the amount 
of sugar excreted. The next step is to cut off all 
forms of carbohydrates and try to render the pa- 
tient aglycosuric. The following outline will assist: 

Breakfast. Tea or coffee, g vj ; beefsteak or mut- 
ton chops without bone, or boiled ham, giv; one or 
two eggs. 

Lunch. Cold roast beef, g vij ; celery, fresh cucum- 
bers, or tomatoes, with vinegar and olive oil, gij; 
pepper and salt to taste; water, gxv; coffee, gij, 
without milk or sugar. 

Supper. Clear bouillon, g x; roast beef, g vij; but- 
ter, 3 iij ; green salad, g ij, with vinegar, 3 ij, and 
olive oil, 5 vj ; water, g xv. 

One or two raw eggs may be given at bedtime and 
water, g xv. 

The amount of sugar in the urine will drop, but, 
should a small amount continue, it is best then to 
have a i i fast day,' ' when the patient takes no 
nourishment for twenty-four hours, when it will be 
found that the patient is not excreting sugar. The 
diet should be carefully arranged for each indi- 
vidual case. 

Skin. Baths should be taken frequently. Warm, 
or even cold if the patient is robust. Some carbol- 
ized soap should be used to wash the skin. Flannel 
should be worn. 

Light exercise or massage should be used, and all 
worry should be avoided and a quiet, even life lived. 



270 CONSTITUTIONAL DISEASES. 

The alkaline mineral waters should be used freely. 
From 3 to 6 ounces of Vichy may be drunk half an 
hour before each meal, or Apollinaris may be 
ordered in much larger quantities. 

Medicinal. Opium is the only drug that is worthy 
of trial. It should be borne in mind that diabetics 
have a great tolerance for it. Codein may be used, 
and, as it is less constipating, is preferable. Codein 
in %-grain doses should be given three times daily 
and gradually increased until 4 or 5 grains are 
taken. 

Opium may be exhibited in many ways, as: 

I£ Extraeti opii gr. xv 

Extracti gentianse q. s. 

Misce et fiat massa. Divide in pilulae No. XXX. 
Sig.: 3 to 12 pills daily. 

Or: 

B Extracti opii gr. ss-gr. j 

Extracti belladonnas . . . gr. ss 

Sacchari lactis gr. v 

Misce et fiant pulveres. Dentur tales doses No. XXV. 

Sig.: 3 powders daily. 

Arsenic is very useful in many cases. It may be 
added to either of the above mixtures, or, better, it 
may be given as Fowler's solution, gradually in- 
creasing the dosage until saturation. 

Coma. There is nothing that equals venesection 
and withdrawal of blood, and replacing it with a 
1 or 2-percent solution of sodium bicarbonate in nor- 
mal salt solution; 1 or 2 pints may be run into a vein 
every three or four hours if necessary. As a rule, 



DIABETES MELLITUS. 271 

this is only a temporary relief, and there is recur- 
rence and death. 

Remember that by administering sodium bicar- 
bonate at frequent intervals it may be possible to 
postpone an attack of coma, which is an acidosis. 



CHAPTEE XIII. 
GENERAL CONSIDERATIONS. 

Physician and Patient. 

One of the most essential things is the patient's 
confidence, and this can not be obtained by loud, 
boisterous talking, scolding, fault-finding, or undue 
jocularity. On the other hand, undue timidity or 
lack of self-confidence is equally bad. The patient 
must be in complete "en rapport' ' with the exam- 
iner if the most is to be accomplished. 

In no other field is it more important to have ac- 
curate knowledge of anatomy. It is essential that 
the examiner be familiar with regional anatomy — 
know the location and size of the organs in health 
and their physiological variations before any accu- 
rate idea can be had of pathological conditions. 

The examiner must be alert, and use all his per- 
ceptive faculties. Often observations of a patient 
during conversation give very definite information. 

It is essential that the physical examinations be 
conducted in a routine manner. More errors of diag- 
nosis come from the want of system than from the 
lack of knowledge. 

Never attempt to make a physical examination 
through the clothing. It is impossible to elicit 
physical signs through heavy clothing, starched 

272 



PHYSICIAN AND PATIENT. 273 

linen, or the corset, while the crackling, friction 
sounds of certain fabrics will obscure auscultation. 

Remember that careful study in the post-mortem 
room is essential to good work at the bedside. Fre- 
quent study of mistakes is always beneficial. 

Be thorough in physical examination, but that 
does not mean that you should be rough. There is 
nothing else that will so quickly secure complete 
co-operation of the patient as gentle manipulation. 
This can be done only by taking plenty of time, 
with the patient in an accessible position, and know 
what you are trying to do. 

Never mistake a guess for a diagnosis. These 
"snap" diagnoses are only guesses, and have 
brought more disappointment than glory, but, if 
only the physician's reputation suffered, it would 
not be so bad. 

Always obtain a history, not only of the mode of 
onset of the present ailment, but the past complaints 
and of the family, especially of any fatal illness of 
the family. This will give a clew as to the inherited 
tendencies of the patient. 

Where a patient is confined to his bed, always 
note his posture in bed. Where the attitude is lax 
and his position controlled by gravity, and he re- 
mains in cramped and uncomfortable postures, such 
a patient is very weak, helpless, or unconscious, and 
is said to assume the passive position. On the other 
hand, the less the general feelings are affected, the 
more natural and unconstrained will be his position. 



274 GENERAL CONSIDERATIONS. 

Again, a patient with respiratory, cardiac, or renal 
affections, associated with much dyspnea, can not 
lie upon his back, because the accessory muscles of 
respiration can be used to advantage only in sitting 
posture. 

Patients are constrained to lie upon one side be- 
cause of unilateral affection of the thoracic viscera. 
The patient usually lies upon the abdomen in colic, 
cardialgia, and sometimes intestinal obstruction, 
while in peritonitis the abdomen is tender and the 
patient lies upon his back. 

The state of nutrition should be noted. Chronic 
conditions are usually associated with emaciation. 
Edema of the skin and subcuticular fat should be 
distinguished. Eemember that edema pits on pres- 
sure with the thumb and the depression very slowly 
disappears. 

Observe the color of the skin. Note whether there 
be pallor. Don't forget the peculiar, waxy pallor of 
nephritis. Again, cyanosis of the skin and mucous 
membranes denotes either an insufficient oxidation 
or an obstruction to the venous return. 

Remember that jaundice is significant of biliary 
trouble. The darker shades signify an obstruction 
of long duration. 

Many of the serious diseases cause undue pigmen- 
tation of the skin. Thus, melano sarcoma is accom- 
panied by a diffuse gray to a black discoloration, pul- 
monary tuberculosis is sometimes associated with a 
decided brownish discoloration of the face, while 



PHYSICIAN AND PATIENT. 275 

Addison's disease causes a smoky-gray to a bronze 
discoloration. 

Remember that enlarged veins or arteries in the 
skin suggest collateral circulation, dne to some deep- 
seated obstruction. The veins of the thoracic wall 
are enlarged with mediastinal or pulmonary tumors 
that compress the big veins within the chest. En- 
larged veins may also be found over the abdomen, 
due to portal obstruction. The veins about the navel 
become enlarged, forming the caput madusae. Ab- 
dominal tumors will cause obstruction by pressure. 
Examine the skin over the abdomen for nodular 
growths, and, when found, remember they are ex- 
tremely significant of malignant growths of the ab- 
dominal cavity. 

Observe the fingers, and note whether they are 
clubbed. The clubbing is due to a swelling of the 
terminal phalanges, and is seen only in congenital 
heart disease, chronic pulmonary disease, most fre- 
quently in bronchiectasis and empyema, but some- 
times in phthisis. 

In fever it is very important to watch the daily 
course of the temperature, as many affections have 
a somewhat characteristic course, as typhoid, ma- 
laria, lobar pneumonia, etc. 

Always observe the respirations. Note their fre- 
quency, the type — whether costal or abdominal — 
the expansion of the two sides of the chest, and 
note any impairment or bulging of either side or 
the intercostal spaces. 



276 GENERAL CONSIDERATIONS. 

In observing the pulse, note the frequency, 
volume, tension, and regularity. Palpate the wall 
of the vessel to determine the presence of arterio- 
sclerosis. A good method to determine sclerosis is 
to grasp the patient's wrist with the left hand and 
elevate the forearm. With the forefinger of the 
right hand make compression on the radial artery 
strong enough to destroy the perception of the pulse 
with the middle finger just below the point of com- 
pression. Then, if the vessel can be rolled under 
the middle finger, sclerosis exists. 

Remember that the pulse rate is increased by 
fever, during digestion, and by coughing. The tem- 
perature and pulse curve in fever usually run par- 
allel. The pulse increases eight beats for every 
degree of fever. In some conditions we find high 
temperature with slow pulse, as in febrile brain 
disease and tubercular meningitis. 

A slow pulse rarely occurs as an individual pecu- 
liarity, but it is found in " fatty,' ' infiltrated heart 
and sclerosis of the coronary arteries. 

A capillary pulse is most frequently observed in 
aortic insufficiency. It is best appreciated by ob- 
serving the alternate blushing and pallor of the 
finger nail. A clean glass slide pressed lightly upon 
the extended lower lip will sometimes bring it out 
when it can not be observed in the finger nail. An- 
other useful method is to rub a spot on the forehead 
until it becomes hyperemic and look for an alterna- 
tion of redness and pallor. 



PHYSICIAN AND PATIENT. 277 

A liver pulse may be felt as a pulsation along the 
lower border. It is found most often in valvular 
lesion of the heart. 

Always examine the excretions and secretions of 
the body. For methods and significance of findings 
consult some work on that subject. 

Remember that palpation is the most valuable of 
the methods of examining the abdomen. The pa- 
tient should lie in bed and the abdomen should be 
bared. The hands of the physician should be 
warmed, and palpation should be done by gentle 
pressure. Frequently the tips of the fingers used 
in palpating reveal more than the palms. 

There are two ways of palpating the abdomen, 
and the one to use depends upon the part to be pal- 
pated. Thus, bimanual palpation may be from side 
to side, the wall of the abdomen being deeply folded 
between the hands. Any accessible organ or tumor 
may thus be studied. Or the lateral regions of the 
abdomen are best palpated by placing one hand 
posteriorly and the other anteriorly. In this man- 
ner the liver may be raised against the anterior wall 
and the lower border examined, or a palpable kid- 
ney brought within the grasp of the palpating hands, 
or the splenic enlargement studied, or carcinoma of 
the sigmoid flexure palpated. By this method deep 
fluctuation may be elicited in renal or appendiceal 
abscess or a hydronephrosis studied. Where tender- 
ness exists, it is better to watch the expression of 
the patient's face than to depend upon any state- 
ment he may make. 



278 GENERAL CONSIDERATIONS. 

In palpating an abdomen, always distinguish be- 
tween superficial and deep tenderness. The super- 
ficial is due to hyperesthesia of the skin, and a light 
touch causes more pain than firm pressure. This 
condition is frequent in hysterical women. 

Pain caused by deep pressure signifies an inflamed 
or congested organ. 

Excessive abdominal fat will prevent obtaining 
accurate information by palpation. 

When the abdominal muscles become tense, due 
to apprehension, excitement, or other nervous 
causes, elevate the head upon pillows and have the 
limbs flexed at hips and knees. 

Use should be made of respiration in palpating 
abdominal organs. Thus, continuous deep breath- 
ing will be very helpful in determining either the 
borders of an organ or to what organ a tumor prob- 
ably belongs, or, again, rapid breathing will assist. 

There must be a systematic examination of the ab- 
domen. The following outline will be of assistance 
and is given merely as a guide: 

1. Condition of the abdominal wall. 

2. Fluctuation, general and local. 

3. Pulsation, thrill, and fremitus. 

4. Eespiratory, postural, and manipulative move- 
ments of organs or tumors. 

5. Peristaltic and fetal movements. 

6. Outline and relation of palpable tumors. 

7. Density and elasticity of the tumors. 

8. Nature of the surface of the tumors. 



INDEX. 



Abscess of the liver (see Diseases 

of the liver) 
Acute bronchitis (see Diseases of 
the lungs and pleurae) 
endocarditis ( see Diseases of the 

vascular system) 
enteritis (see Diseases of the in- 
testines ) 
nephritis (see Diseases of the 

kidneys and bladder) 
pancreatitis (see Diseases of the 

pancreas and peritoneum) 
peritonitis (see Diseases of the 

pancreas and peritoneum) 
pleurisy (see Diseases of the 

lungs and pleurae ) 
yellow atrophy (see Diseases of 
the liver) 
xiddison's disease (see Diseases of 

the ductless glands) 
Alcoholic cirrhosis (see Diseases 
of the liver — Portal cirrhosis) 
Amebic dysentery (see Infectious 

diseases ) 
Anemia, pernicious (see Diseases 

of the blood) 
Angina pectoris (see Diseases of 

the valvular system) 
Appendicitis (see Diseases of the 

intestines ) 
Arteriosclerosis (see Diseases of 
the valvular system) 
test for, 276 
Arthritis deformans (see Constitu- 
tional diseases) 
Asthma, bronchial (see Diseases of 

the lungs and pleurae) 
Atrophy, acute yellow (see Dis- 
eases of the liver) 

B 

Bacillary dysentery ( see Infectious 

diseases) 
Biliary cirrhosis (see Diseases of 

the liver) 



Bladder, diseases of the (see Dis- 
eases of the kidneys and 
bladder ) 

Blood, diseases of the (see Dis- 
eases of the blood) 

Bowel, obstruction of the ( see Dis- 
eases of the intestines) 

Bronchial asthma (see Diseases of 
the lungs and pleurae ) 

Bronchiectasis (see Diseases of the 
lungs and pleurae) 

Bronchitis, acute (see Diseases of 
the lungs and pleurae ) 
chronic (see Diseases of the 
lungs and pleurae) 

Broncho-pneumonia ( see Diseases 
of the lungs and pleurae) 



Cancer, gastric (see Diseases of 
the stomach) 

of the liver (see Diseases of the 
liver) 
Carcinoma of the pancreas (see 
Diseases of the pancreas and 
peritoneum) 
Cholangeitis, suppurative (see Dis- 
eases of the gall bladder) 
Chlorosis (see Diseases of the 

blood) 
Chronic bronchitis (see Diseases of 
the lungs and pleurae) 

constipation ( see Diseases of the 
intestines ) 

enteritis (see Diseases of the in- 
testines) 

interstitial nephritis (see Dis- 
eases of the kidneys and 
bladder) 

interstitial pneumonia (see Dis- 
eases of the lungs and 
pleurae ) 

pancreatitis (see Diseases of the 
pancreas and peritoneum) 

parenchymatous nephritis ( see 
Diseases of the kidneys and 
bladder) 



279 



280 



INDEX. 



Cirrhosis, alcoholic (see Diseases 
of the liver — Portal cir- 
rhosis ) 
biliary (see Diseases of the 

liver ) 
Lsennec's (see Diseases of the 

liver — Portal cirrhosis ) 
portal (see Diseases of the liver) 
Colitis, mucous (see Diseases of 

the intestines) 
Considerations, general (see Gen- 
eral considerations) 
Constipation, chronic ( see Diseases 

of the intestines) 
Constitutional diseases, 260 
Arthritis deformans, 260 
Heberden's nodes, 261 
joint changes, 260 
joint destruction, 260 
joint distortion, 262 
joint restoration, 260 
joint swelling, 261 
muscular atrophy, 261 
onsets vary, 260 
pain spontaneous, 260 
pigmentation of skin^ 261 
pulse, 261 

simulating rheumatism, 260 
symptoms, 261 
Treatment, 262 
baths, 262 
diet, 262 

Fowler's solution, 262 
massage, 262 
medicinal, 262 
rest, 262 

superheated air, 262 
Diabetes mellitus, 267 
coma, 268 
diabetic tabes, 268 
examination of urine, 268 
gangrene, 268 
signs, 267 
symptoms, 267 
urinalysis, 268 
Treatment, 269 
clothing, 269 
coma, 270 
diet, 269 
exercise, 269 
fatality, 271 
massage, 269 



Constitutional diseases — cont'd 
medication, 269 
prescriptions, 270 
skin, 269 
venesection, 270 
Gout, 263 

aortic second sound, 265 
arteriosclerosis coexistent, 263 
arthritis, 263 
causes, 263 
family history, 264 
gastrointestinal catarrh, 264 
gouty diathesis, 264 
leucocytosis, 264 
liquor as cause, 263 
lithemia, 264 
nutritional disorder, 263 
occupation, 264 
premonitory signs, 263 
recurrent attacks, 263 
symptoms, 263, 264 
uric acid, 263 
Treatment, 265 
acute attack, 265 
diet, 266 
exercise, 266 
lithemic patients, 267 
medication, 265 
prescriptions, 265, 266 
relief of pain, 265 
symptoms of poisoning, 

266 
uric acid, 266 
Cystitis (see Diseases of the kid- 
neys and bladder) 
Cysts, pancreatic ( see Diseases of 
the pancreas and perito- 
neum) 



Diabetes mellitus (see Constitu- 
tional diseases) 

Diphtheria (see Infectious dis- 
eases) 

Disease, Addison's (see Diseases of 
the ductless glands) 
Hodgkin's (see Diseases of the 

blood — Pseudoleukemia ) 
of the heart, valvular (see Dis- 
eases of the vascular sys- 
tem) 



INDEX. 



281 



Diseases, constitutional (see Con- 
stitutional diseases) 
infectious (see Infectious dis- 
eases ) 
Diseases of the blood, 102 
Chlorosis, 102 
anemia test, 102 
capricious appetite, 102 
causes, 102 

hyperacidity of stomach, 103 
symptoms, 102 
Treatment, 103 

atony of bowels, 104 
Blaud's pills, 104 
constipation, 104 
diet, 103 
electricity, 103 
exercise, 103 
gastralgia, 104 
massage, 103 
prescriptions, 104-106 
rest, 103 
Leukemia, 108 

enlargement of lymph glands, 

109 
enlargement of spleen, 109 
enlargement of tonsils, 109 
hematemesis, 109 
lymphemia, 109 
necrosis, 109 
onset insidious, 108 
symptoms, 108 
Treatment, 110 
diet, 110 

Fowler's solution, 110 
fresh air, 110 
rest, 110 
x-ray, 110 
Pernicious anemia, 106 

circulatory disturbances, 107 
examination of blood, 107 
jaundice, 106 
nervous symptoms, 106 
onset insidious, 106 
peripheral neuritis, 106 
pulse, 107 

spastic paraplegia, 106 
symptoms, 106 
tabes dorsalis, 106 
Treatment, 107 
diet, 107 
Fowler's solution, 107 



Diseases of the blood — cont'd 
fresh air, 107 
hypodermoclysis, 108 
rest, 107 
Pseudoleukemia (Hodgkin's dis- 
ease), 110 
blood count, 111 
chronic tonsillitis, 110 
enlargement of the axillary 

glands, 111 
enlargement of the inguinal 

glands, 111 
examination of blood, 110 
examination of teeth, 110 
histologic changes, 111 
periadenitis, 111 
pressure symptoms, 111 
pruritus, 111 
recurring boils, 111 
temperature curve, 111 
tubercular adenitis, 111 
tuberculous glands of neck, 
111 
Treatment, 112 

Fowler's solution, 112 
prescriptions, 112 
surgery, 112 
x-ray, 112 
Purpura, 113 

erythematous eruptions, 113 
hemorrhage, 113 
macular eruptions, 113 
papular eruptions, 113 
purpura rheumatica, 113 
symptoms, 113 
tonsillitis, 113 
urti carious eruptions, 113 
Treatment, 114 
cathartics, 114 
diet, 114 

prescriptions, 114, 115 
Diseases of the ductless glands, 116 
Addison's disease, 116 
asthenia, 117 
gastric disturbances, 116 
muscular prostration, 117 
onset insidious, 116 
pigmentation, 116 
symptoms, 116 
tubercular degeneration of 

glands, 117 
tuberculin test, 117 



282 



INDEX. 



Diseases of the ductless glands — 
cont'd 

Treatment, 117 

diarrhea, 117 

diet, 117 

organotheraphy, 118 

prescriptions, 117, 118 

rest, 117 
Exophthalmic goiter, 118 
common in women, 118 
edema of feet, 120 
emaciation, 120 
exophthalmos, 118, 119 
goiter, 118 
Grafe's sign, 119 
Joffroy's sign, 119 
mental condition, 120 
Mobius' sign, 119 
pulsation, 118, 119 
Stell wag's sign, 119 
sweating, 120 
symptoms, 118 
tachycardia, 118, 119 
test for tremor, 120 
tremor, 118, 120 
tumor, 118 

Treatment, 120 

Beebe and Rogers' serum, 
122 

diet, 121 

electrotherapy, 121 

ForcheinierV method, 122 

fresh air, 121 

hydrotherapy, 121 

medication, 121 

Merck's serum, 122 

Ortner's method, 122 

prescriptions, 121 

rest, 120 

rodagen, 122 

surgery, 122 
Myxedema, 123 

atrophy of thyroid, 123 
causes, 123 
cretinism, 123 
facial expression, 124 
mental dullness, 124 
onset insidious, 124 
symptoms, 123, 124 
Treatment, 125 

extract of thvroid gland, 
125 



Diseases of the ductless glands — ■ 
cont'd 

Forcheimer's dosage, 125 
infantile form of cretin- 
ism, 125 
prescriptions, 125 
symptoms in children, 126 
Diseases of the gallbladder, 57 
Gallstones, 57 

area of tenderness, 58 
catarrhal inflammation, 57 
causes, 57 
friction sound, 58 
gallstone colic, 57 
gastralgia, 58 
hematemesis, 58 
peptic ulcer, 58 
pulse, 57 
sweating, 57 
symptoms, 57 
vomiting, 57 
Treatment, 58 
acute attack, 58 
chloroform inhalations, 58 
dissolving stones, 59 
gallstone colic, 58 
hypodermatic, 58 
interval, 58, 59 
prescriptions, 59 
surgery, 60 
Suppurative cholangeitis, 60 
causes, 60 
gallbladder, 61 
icterus, 60 
infection, 60 
leucocytosis, 61 
malaria, 61 
pain variable, 60 
pancreatic ducts, 60 
progressive hepatic enlarge- 
ment, 60 
symptoms of active infection, 
60 

Treatment, 61 
surgery, 61 
Diseases of the intestines, 26 
Acute enteritis, 26 
albumin casts, 26 
causes, 26 
colic, 26 

diarrhea dominant svmptom. 
26 



INDEX. 



283 



Diseases of the intestines — cont'd 

edema, 26 

fever, 27 

pain varies, 26 
Treatment, 27 
cathartics, 27 
colon irrigation, 28 
continual seepage, 29 
diet, 28 

hypodermatic, 27 
medicinal, 28 
prescriptions, 28, 29 
sudorifics, 27 
technic of continual seep- 
age, 29 
Appendicitis, 37 

dyspepsia in masked, 38 

diarrhea in masked, 38 

examination in masked, 39 

fever, 37 

gangrene, 37 

masked, 38 

masking of symptoms, 38 

pain in masked, 39 

palpation in masked, 39 

perforation, 37 

symptoms, 37 

tenderness about rectum, 38 

tenderness at McBurney's 
point, 38 

typhoid bacilli, 38 
Treatment, 39 

continuous seepage, 39 
Ochsner's method, 39 
perforation probable, 39 
peritonitis probable, 39 
surgery, 39 

washing out stomach, 39 
Chronic constipation, 34 

causes, 34 

colic, 35 

colonic ulceration, 34 

diarrhea, 34 

dysmenorrhea, 34 

occlusion of bowel, 34 

perforation, 34 

piles, 34 

sacral neuralgia, 34 

symptoms, 35 
Treatment, 35 
diet, 35 
drugs, 35 



Diseases of the intestines — cont'd 

enemata, 35 

massage, 35 

physical exercise, 35 

prescriptions, 35, 36 

stools, 35 
Chronic enteritis, 30 
colicky pains, 30 
colitis, 30 
constipation, 30 
diarrhea, 30 

examination of stools, 30 
indications of enteritis, 30 
sago-pearls, 30 
Treatment, 30 

astringents, 31 

colon irrigation, 31 

diet, 30 

examination of stools, 30 

laxatives, 31 

medicinal, 31 

prescriptions, 31, 32 
Mucous colitis, 40 
colicky pain, 40 
neurosis, 40 
symptoms, 40 
tenderness over colon, 40 
tenesmus, 40 
urticaria, 40 
Treatment, 40 

diet, 40 

irrigation of colon, 41 

physical exercise, 40 

relief of pain, 41 

Weir-Mitchell feeding, 41 
Obstruction of the bowel, 32 
complete obstruction, 33 
distention of abdomen, 32 
fecal retention, 32 
iliocecal junction, 33 
intussusception, 33 
symptoms vary, 32 
tenesmus, 33 
termination, 33 
tumor, 33 

Treatment, 34 

cathartics, 34 

enemata, 34 

purgatives, 34 

surgery, 34 
Visceroptosis, 41 
symptoms, 42 



284 



INDEX. 



Diseases of the intestines — cont'd 
technic to determine displace- 
ment, 41 
Treatment, 43 

caution, 44 

diet, 43 

mechanical support, 43 

medicinal, 44 

Weir-Mitchell feeding, 43 
Diseases of the kidneys and blad- 
der, 71 
Acute nephritis, 73 
albumin, 74 
anasarca, 73 
anemia, 74 
Bright's disease, 73 
causes, 73 
dropsy, 73 

examination of urine, 74 
pleural effusions, 74 
scarlatina, 73 
syphilitic nephritis, 74 
typhoid, 73 
uremia, 73 
Treatment, 74 

diaphoretics, 77 

diet, 75 

diuretics, 76 

etiological factor, 74 

purging, 77 

malaria, 74 

Petit's triangle, 75 

prescriptions a 76-78 

salicylic acid, 75 

symptomatic, 75 

syphilis, 74 

venesection, 75 
Chronic interstitial nephritis, 81 
arteriosclerosis, 81 
cardiovascular findings, 81 
chronic bronchitis, 82 
edema, 82 

enlarged prostate, 81 
hypertrophy of heart, 82 
impaired vision, 82 
pulse, 82 

retinal findings^ 81 
urinary findings, 81 
urine, 81 

Treatment, 82 

arterial tension, 83 

bowels, 83 



Diseases of the kidneys and blad- 
der — cont'd 

clothing, 83 

diet, 82 

diuretics, 82 

skin, 83 

syphilitic nephritis, 83 

worry, 83 
Chronic parenchymatous nephri- 
tis, 78 
albuminuria retinitis, 79 
anemia, 78 
asthma, 79 
edema, 78 
epilepsy, 78 
uremic dyspnea, 78 
urine, 78 
vomiting, 79 
Treatment, 79 

Basham's mixture, 81 

baths, 80 

bowels, 81 

clothing, 80 

diet, 79 

diuretics, 81 

rest, 79 

salt, 80 

water, 80 
Cystitis, 98 
bacteria, 98 

examination of bladder, 98 
hypertrophied bladder, 98 
interrupted micturition, 98 
tubercle bacilli, 98 
tubercular cystitis, 98 
urinalysis, 98 
Treatment, 99 

cathartics, 99 

causal therapy, 100 

chronic form^ 100 

crushing stone, 99 

diet, 99 

prescriptions, 99-101 

relief of pain, 99 

removal of stone, 99 

urinary antiseptics, 99 
Hydronephrosis, 91 
aspiration, 91 
congenital, 91 
mistaken for ascites, 91 
mistaken for ovarian cysts, 91 
tumor, 91 



INDEX. 



285 



Diseases of the kidneys and blad- 
der — cont'd 

Treatment, 92 

aspiration, 92 

bandage, 92 

drainage, 92 

incision, 92 

nephrectomy, 92 
Movable kidney, 71 
floating kidney, 71 
hydronephrosis, 72 
hysteria, 71 
jaundice, 72 
nephroptosis, 72 
palpable kidney, 71 
palpation, 71 
symptoms, 72 
Treatment, 72 

bandage, 72 

forced feeding, 72 

rest, 72 

surgery, 73 

tonic, 73 
Nephrolithiasis, 92 
cause of stones, 92 
focus of pain, 93 
hematuria, 93 
gravel, 92 
renal calculi, 93 
renal colic, 92 
sand, 92 
stone, 92 
symptoms, 93 
vesical calculi, 93 
x-ray, 93 

Treatment, 94 

baths, 94 

chloroform inhalations, 94 

diet, 96 

dyspepsia, 97 

examination of urine, 94 

hyperacidity, 97 

neurasthenia, 97 

prescriptions, 94-97 

renal colic, 94 

surgery, 97 
Pyelitis, 89 
cystitis, 89 

painful micturition, 89 
polyuria, 89 
pyuria, 89 
reaction of urine, 89 



Diseases of the kidneys and blad- 
der — cont'd 
symptoms, 89 
tumor, 89 

Treatment, 89 

antiseptics, 90 

astringents, 91 

baths, 89 

congestion, 90 

diet, 89 

gastric disturbances, 90 

leeches, 90 

prescriptions, 90, 91 

relief of pain, 90 
Uremia, 84 

albuminuric retinitis, 85 
asthenia, 84 
brain tumor, 85 
Bright's disease, 84 
Cheyne- Stokes breathing, 84 
coma, 84, 85 
headache, 84 
hemiplegia, 84 
impaired vision, 84 
latent form, 84 
meningitis, 85 
miliary tuberculosis, 85 
muscular cramps, 84 
odor of breath, 86 
pulse, 84 

uremic dyspnea, 84 
urinalysis, 84 
vomiting, 84 
Widal reaction, 85 
Treatment, 86 

acute attack, 86, 88 

cardiac tonics, 86 

cathartics, 86 

chronic attack, 88 

convulsions, 87 

diaphoretics, 86 

diarrhea, 88 

diet, 88 

lavage, 88 

prescriptions, 86-88 

Renon's water diet, 88 

uremic asthma, 88 

venesection, 86 

vomiting, 87 
Diseases of the liver, 45 
Abscess of the liver, 52 
cases resemble malaria, 53 



286 



INDEX. 



Diseases of the liver — cont'd 
causes, 53 

dislocation of heart, 54 
enlarged liver, 53 
puncturing of liver, 54 
uncertainty of diagnosis, 52 
Treatment, 54 

inefficacy of drugs, 54 

preventive, 54 

surgery, 54 
Acute yellow atrophy, 54 
biliary cirrhosis, 54 
coma, 54 

pregnancy a factor, 54 
reduction of liver, 55 
symptoms, 54 
urinalysis, 55 
Treatment, 55 

cathartics, 55 

gastric sedatives, 55 
Biliary cirrhosis, 51 
cancer of liver, 52 
chronic icterus, 51 
chronic jaundice, 51 
enlarged spleen, 51 
gallstones, 51 
Hanot's cirrhosis, 51 
hemorrhage, 51 
heredity as factor, 51 
malignant disease of liver, 51 
symptoms, 51 
Treatment, 52 

bowels, 52 

diet, 52 

quiet life, 52 
Cancer of the liver, 55 
ascites, 56 
age when occurs, 55 
enlarged liver, 56 
enlarged lymph glands, 56 
emaciation, 56 
fatality, 56 
icterus, 56 
liver dullness, 56 
nodular form, 55 
primary, 55 
secondary, 55 
tumor form, 55 
uncertainty of diagnosis, 55 
Treatment, 56 

palliative, 56 

surgery, 56 



Diseases of the liver — cont'd 
Icterus (jaundice), 45 
a symptom, 45 
causes, 45 

examination of gallbladder, 45 
examination of liver, 45 
examination of urine, 45 
hemorrhage, 45 
pulse, 45 
respirations, 45 
stools, 45 
test for, 45 
Treatment, 46 
diet, 46 
enemata, 46 
prescriptions, 46, 47 
purgatives, 46 
Portal cirrhosis (Lsennec's cir- 
rhosis, alcoholic cirrhosis ) , 
47 
albumin, 48 
alcoholic history, 47 
examination of pelvis in wom- 
an, 48 
hemorrhage, 48 
nodules of liver, 48 
nutmeg liver, 48 
ovarian cyst, 48 
urea excretion, 48 
Treatment, 48 
alcohol, 48 
ascites, 49, 50 
bowels, 49 
diarrhea, 49 
diet, 48 

hematemesis, 49 
prescriptions, 49, 50 
surgery, 50 
Diseases of the lungs and pleurae, 
163 
Acute bronchitis, 163 
atelectasis, 164 
bronchial fremitus, 164 
bronchi-pneumonia, 164 
capillary bronchitis, 164 
Charcot's crystals in sputum, 

164 
cough, 163 
dyspnea, 164 

examination of chest, 164 
fever, 163 
fremitus, 164 



INDEX. 



287 



Diseases of the lungs and pleurae — 
cont'd 

percussion sound, 164 
prolonged expiration, 163 
spirals in sputum, 164 
substernal soreness, 163 
symptom in malaria, 163 
symptom in typhoid, 163 
vesicular murmur, 163 
Treatment, 164 
baths, 164 
bowels, 165 
diet, 167 
foot bath, 164 
mustard plaster, 164 
prescriptions, 165-167 
Acute pleurisy, 211 
auscultation, 211 
differentiating pleurisy and 

pneumonia, 213 
displacement of organs, 213 
dyspnea, 211 

effusion into pleural sac, 212 
fever, 211 
focus of pain, 211 
Grocco's triangle of dullness, 

212 
posture of patient, 212 
Skoda's resonance, 212 
symptoms, 211 
tumor of mediastinum, 213 
withdrawal of fluid, 213 
Treatment, 213 
aspiration, 214 
diet, 214 

Potain's aspirator, 214 
prescriptions, 215 
rest, 213 

technic of aspiration, 214 
Bronchial asthma, 175 

appearance of patient, 175 
Charcot's crystals, 176 
Curschmann spirals, 176 
dyspnea in bronchial asthma, 

176 
dyspnea in cardiac asthma, 176 
eosinophils of blood, 176 
expiration, 175 
inspiration, 175 
premonitory symptoms, 175 
spasm of glottis, 176 
sputum, 175 



Diseases of the lungs and pleurae — 
cont'd 

symptoms, 175 
symptoms of dyspnea, 176 
symptoms of emphysema, 176 
Treatment, 176 
attack, 176, 177 
bowels, 179 
change of climate, 179 
chloroform inhalations, 

177 
chronic hronchitis, 179 
diet, 179 
emphysema, 179 
interval, 176, 178 
nitrite of amyl, 177 
prescriptions, 178, 179 
Bronchiectasis, 172 
cerebral abscess, 173 
cough, 173 
grippe, 172 
sputum, 172 
symptoms, 173 
tuberculosis of lungs, 173 
Treatment, 173 

internal antiseptics, 173 
prescriptions, 173, 174 
surgery, 174 
vapor bath, 174 
Broncho - pneumonia ( lobular 
pneumonia), 190 
age when occurs, 190 
Bright's disease, 190 
cyanosis, 190 
dyspnea, 190 
miliary tuberculosis, 191 
percussion, 191 
symptoms, 190 
terminal event, 190 
tubercle bacilli, 190 
Treatment, 191 
bowels, 191 
diet, 193 
fever, 191 
pulse, 193 

prescriptions, 192, 193 
proper care of child, 191 
tonics, 193 
venesection, 193 
Chronic bronchitis, 167 
bronchorrhea, 168 
coexisting emphysema, 168 



288 



INDEX. 



Diseases of the lungs and pleurae — 
cont'd 

examination of heart, 168 
examination of urine, 168 
lung tissue in sputum, 168 
occupation a factor, 167 
secondary to other conditions, 

167 
shortness of breath, 168 
symptoms, 168 
tubercle bacilli, 168 
uric acidemia, 168 
winter's cough, 168 
Treatment, 169 

bowels, 169 

change of climate, 169 

clothing, 169 

diet, 169 

dry catarrh, 169 

moist catarrh, 169 

nephritis, 172 

prescriptions, 169-172 
Chronic interstitial pneumonia, 
194 
apex beat of heart, 194 
atrophy of lung, 194 
auscultation, 194 
cardiac failure, 195 
chronic cough, 195 
dyspnea, 195 
hemorrhage, 195 
history, 194 
sputum, 195 
tuberculosis, 195 
Treatment, 195 

breathing exercise, 195 

change of climate, 195 

clothing, 195 

diet, 195 

severe cough, 195 

skin, 195 
Edema of the lungs, 179 
acute edema, 180 
cyanosis, 180 
due to engorgement, 180 
dyspnea, 180 

exudations into alveoli, 179 
fatality, 180 
inflammatory, 180 
onset sudden, 180 
pulse, 180 
second pulmonic sound, 180 



Diseases of the lungs and pleurae — 
cont'd 

sputum, 180 
Treatment, 180 

bleeding, 180 

cardiac stimulants, 180 

dry cupping, 181 

mustard draft, 181 

purging, 181 
Emphysema, 196 
bronchitis, 196 
cough, 196 
cyanosis, 196 
dyspnea, 196 
expectoration, 196 
heredity, 196 

hypertrophy of right heart, 196 
percussion, 196 
second pulmonic sound, 196 
symptoms, 196 
Treatment, 197 

asthmatic attacks, 197 

bowels, 197 

chronic bronchitis, 197 

diet, 197 

Fowler's solution, 197 

protection from exposure, 
197 
Lobar pneumonia, 181 

acute tuberculo - pneumonic 

phthisis, 185 
aspirator needle, 185 
auscultation, 183 
broncho-pneumonia, 184 
cardiac dullness, 183 
cerebrospinal meningitis, 184 
chill, 181 
cyanosis, 181 
dyspnea, 181 
fever, 181 

focus of pain, 181, 182 
heart failure, 183 
hemorrhagic infarct, 184 
Kernig's sign, 184 
leucocytosis, 184 
onset sudden, 184 
palpation, 182 
percussion, 182 
pleurisy, 184 
profound toxemia, 183 
pulmonary second sound, 183 
pulse, 182, 184 



INDEX. 



289 



Diseases of the lungs and pleurae — 
cont'd 

respiration, 182 
second heart sound, 183 
Skoda's resonance, 183 
sputum, 181, 184 
symptoms, 182 
urine, 183 

Treatment, 185 

baths, 186 

cold sweating, 188 

conservation of heart, 185 

convalescence, 189 

cough, 187 x 

crisis, 189 

diet, 185 

expectorants, 187 

fresh air, 185 

heart failure, 187 

hypodermoclysis, 189 

isolation, 185 

prescriptions, 187-189 

relief of pain, 186 

rest, 185 

skin, 186 

sleeplessness, 187 

strapping of chest, 186 

tympanites, 186 

venesection, 187 
Pulmonary gangrene, 197 
fever, 198 
sequence of lung conditions, 

197 
sputum, 198 
symptoms, 198 
typhoid, 197 
Treatment, 198 

carbolic inhalations, 198 

diet, 198 

position of patient, 198 

prescriptions, 199 

stimulants, 198 

surgery, 199 
Pulmonary tuberculosis, 199 
auscultation, 199, 202 
breathing, 201 
catarrh, 199 
cough, 200 
family history, 202 
hectic fever, 200 
hemorrhage, 201 
Koch's tuberculin, 201 



Diseases of the lungs and pleura? — 
cont'd 

loss of weight, 199 

night sweats, 200 

pain in chest, 201 

percussion, 199 

pulse, 201 

rigid muscles, 201 

sputum, 200 

symptoms, 199 

temperature, 199 

test for tubercular infection, 

201 
tubercle bacilli, 200 
Treatment, 202 

anorexia, 207 

care of mouth, 203 

cough, 208 

diet, 202 

exercise, 203 

fever, 207 

hemorrhage, 208 

inhalations, 204 

medicinal therapy, 203 

mercurial treatment, 210 

night sweats, 208 

prescriptions, 204-209 

skin, 208 

sleeping arrangements, 203 

sputum, 211 

ventilation, 203 
Diseases of the pancreas and peri- 
toneum, 62 
Acute pancreatitis, 63 
intestinal obstruction, 83 
onset sudden, 63 
symptoms, 63 
Treatment, 64 

collapse, 64 

pain, 64 

rectal feeding, 64 

surgery, 64 
Acute peritonitis, 68 
arteriosclerosis, 68 
Bright's disease, 68 
clinical picture, 68 
enterocolitis, 69 
facies, 68 
focus of pain, 68 
gout, 68 

Hippocrates' facies, 69 
hysteria, 69 



290 



INDEX. 



Diseases of the pancreas and peri- 
toneum — cont'd 

inflammation of peritoneum, 

68 
inflammation of viscera, 68 
intestinal obstruction, 69 
mental condition, 68 
pulse, 68 
respiration, 69 
shock, 68 
symptoms, 68 
tuberculosis, 69 
vomiting, 69 
Treatment, 70 

diet, 70 

Fowler's position, 70 

saline treatment, 70 

surgery, 70 
Carcinoma of the pancreas^ 66 
anorexia, 67 
ascites, 67 
bowels, 67 

distention of gallbladder, 66 
edema, 67 

enlargement of liver, 67 
immobile tumor, 67 
interstitial pancreatitis, 67 
jaundice, 67 
retention cysts, 66 
Treatment, 67 

draining, 67 

extirpation of gland, 67 

palliative, 67 

rectal feeding^ 67 
Chronic pancreatitis, 64 
anorexia, 64 
examination of feces, 64 
focus of pain, 64 
gallstones, 64 
glycosuria, 64 
indican, 65 

islands of Langerhans, 64 
jaundice, 64 
onset gradual, 64 
palpation, 64 
Treatment, 65 

anastomosis, 65 

icterus, 65 

surgery, 65 
Hemorrhage, 62 
fatality, 62 
medico-legal view, 62 



Diseases of the pancreas and peri- 
toneum — cont'd 

mistaken for intestinal ob- 
struction, 62 
onset sudden, 62 
pulse, 62 
temperature, 62 
vomiting, 62 
Treatment, 62 

heart depression, 63 
laparotomy, 63 
loss of blood, 62 
pain, 62 
Pancreatic cysts, 65 
causes, 65 
constipation, 65 
examination in Trendelenburg 

position, 66 
glycosuria, 66 
jaundice, 65 
location, 65 
palpation, 65 
shape, 65 
tumor, 65 

tumor of transverse colon, 66 
vomiting, 65 
Treatment, 66 
draining, 66 
surgery, 66 
Diseases of the stomach, 9 
Gastric cancer, 15 
anasarca, 15 
Boas-Oppler bacillus, 16 
duration, 16 
edema, 15 
gastric tumor, 15 
hepatic tumor, 15 
hydrochloric acid, 15 
increasing, 15 
inspection, 16 
lactic acid, 16 
nodular swellings, 15 
pain of carcinoma, 16 
palpation, 16 
symptoms, 15 

symptoms of pancreatic can- 
cer, 16 
tumor, 15 
vomiting, 15 
Treatment, 17 
medicinal, 17 
prescriptions, 17, 18 



INDEX. 



291 



Diseases of the stomach — cont'd 

relief of pain, 17 

surgery, 17 

washing out stomach, 17 
Gastric ulcer, 9 
anemia, 10 
appetite, 11 
area of tenderness, 10 
cause of pain, 9 
dilatation, 10 
enlargement of liver, 11 
evidence, 10 

examination of stools, 11 
focus of pain, 9, 10 
frequency in women, 10 
hemorrhage, 10 
hydrochloric acid, 9 
pain after healing, 10 
pain of gastralgia, 10 
perforation, 10 
relief from pain, 9 
stomach tube, 11 
surgery in perforation, 11 
symptoms, 9 

symptoms of perforation, 11 
vomiting, 9 
Treatment, 11 

fasting, 11 

medicinal, 12 

prescriptions, 13-15 

rectal feeding, 12 

rest of stomach, 11 
Gastritis, 18 

alcohol as factor, 19 
cardiac palpitation, 19 
dyspnea, 19 
gastric catarrh, 19 
history of case, 18 
locomotor ataxia simulates, 18 
majority of cases afebrile, 18 
mistaken for gallstones, 18 
mistaken for infectious dis- 
ease, 19 
mistaken for meningitis, 18 
portal stasis, 19 
test for knee jerk, 18 
test for reaction of pupil, 18 
Treatment, 19 

prescriptions, 19-22 

stomach tube, 19 

vomiting, 19 



Diseases of the stomach — cont'd 
Hematemesis, 24 

anemia, 24 

blood from lungs, 25 

blood from stomach, 25 

edema, 25 

fatal synocope, 24 

leukemia, 25 

rupture of varix, 25 
Treatment, 25 

absolute quiet, 25 
hypodermatic, 25 
hypodermoclysis, 25 
medicinal, 25 
rectal feeding, 25 
surgery, 25 
Hyperchlorhydria, 22 

cancer excluded, 22 

children affected, 23 

chlorosis, 22 

eructation, 22 

examination of stomach, 22 

gastritis excluded, 22 

heartburn, 22 

hydrochloric acid, 22 

hysteria, 22 

neurasthenia, 22 

pain variable, 22 

relief of pain, 22 

salivation, 22 

symptoms in children, 23 

vomiting of sour liquid, 22 
Treatment, 23 
diet, 23 
medicinal, 23 
prescriptions, 23, 24 
washing out stomach, 23 
Diseases of the vascular system, 
127 
Acute endocarditis, 132 

auscultation, 132 

causes, 132 

precordial pain, 132 

pulmonic sound, 132 

simple endocarditis, 132 

symptoms, 132 
Malignant endocarditis, 132 

chills, 133 

emboli, 133 

fever, 133 

history, 132 

sweat, 133 



292 



INDEX 



Diseases of the vascular system — 
cont'd 

symptoms, 133 
Treatment, 133 
diet, 133 
enemata, 134 
rest, 133 

prescriptions, 134, 135 
Angina pectoris, 154 
arteriosclerosis, 155 
common in men, 154 
factors, 154, 155 
neurotic form, 155 
onset sudden, 155 
symptoms, 155 
syphilitic aortitis, 154 
Treatment, 156 
attack, 156 
bowels, 157 
chloroform inhalations, 

156 
diet, 157 
elimination, 157 
hypodermatic injections, 

156 
interval treatment, 156 
nitrite of amyl inhala- 
tions, 156 
prescriptions, 157, 158 
Arteriosclerosis, 158 
attacks transient, 159 
causes, 158 
coronary arteries, 159 
intermittent claudication, 160 
symptoms, 159 
Treatment, 160 
baths, 160 
bowels, 160 
cathartics, 161 
diet, 160 

early diagnosis, 160 
Fowler's solution, 161 
kidneys, 160 
prescriptions, 160, 161 
quiet life, 160 
venesection, 162 
Palpitation, 152 
anemia, 152 
causes, 152 

common in women, 152 
pulse, 152 
neurosis, 152 



Diseases of the vascular system — 
cont'd 
urine, 152 

Treatment, 153 
anemia, 153 
baths, 153 
diet, 153 

gastric disturbances, 154 
prescriptions, 153, 154 
sexual excitement, 153 
Weir-Mitchell treatment, 
153 
Pericarditis, 127 

acute fibrinous stage, 127 
auscultation, 127 
cardiac dilatation, 130 
cardiac dullness, 129 
cardiac effusion, 130 
causes, 127 

constitutional signs, 128 
dysphagia, 129 
dyspnea, 128 
effusion, 128 
first rib sign, 129 
friction sound, 127 
idiopathic varieties, 127 
palpation, 128 

paralysis of vocal cords, 129 
percussion, 129 
physical signs, 128 
pleural effusion, 130 
pulse, 128 
Rotch's sign, 129 
singultus, 129 
symptoms, 128 
triangle sign, 129 
vomiting, 129 
Treatment, 130 
constipation, 131 
diet, 130 
medicinal, 130 
prescriptions, 131 
rest, 131 

technic of aspiration, 131 
Valvular diseases of the heart, 
135 
aortic incompetency, 135 
auscultation, 136 
Austin-Flint murmur, 137 
causes, 135 

examination of arteries, 136 
focus of pain, 135 






INDEX. 



293 



Diseases of the vascular system — 
cont'd 

mental disturbances, 136 

pulse, 136 

symptoms, 135 
aortic stenosis, 137 

arterial changes, 137 

causes, 137 

muscular hypertrophy, 137 

pulmonary emphysema, 137 

pulsus tardus, 137 

symptoms, 137 

systolic thrill, 137 
mitral incompetency, 138 

apex beat, 139 

cardiac sleep start, 139 

clubbing of fingers, 138 

percussion, 139 

physical signs, 139 

pulmonic congestion, 139 

pulse, 139 

symptoms, 138 
mitral stenosis, 140 

common in women, 140 

dullness, 140 

hypertrophy, 140 

location of murmur, 140 

paralysis of vocal cords, 140 
tricuspid insufficiency, 141 

crural vein sound, 141 

expansile pulsation of liver, 
141 

symptoms, 141 

systolic murmur, 141 
tricuspid stenosis, 141 

cardiac dullness, 141 

presystolic murmur, 141 

symptoms, 141 
Treatment, 142 
Addison's pills, 149 
arteriosclerosis, 146 
baths, 142 
cardiac failure, 147 
cardiac stimulants, 144 
cathartics, 142, 149 
clothing, 142 
cough, 150 
diet, 142 
dropsy, 147 
insomnia, 149 
mechanical, 142 
medication, 142 



Diseases of the vascular system — 
cont'd 

Nauheim treatment, 150 
Niemeyer's pills, 149 
paracentesis, 149 
prescriptions, 143-150 
rest, 142 

Schott movements, 150 
venesection, 147 
Ductless glands, diseases of the 
(see Diseases of the ductless 
glands ) 
Dysentery, amebic (see Infectious 
diseases ) 
bacillary (see Infectious dis- 
eases ) 

E 
Edema of the lungs (see Diseases 

of the lungs and pleurae ) 
Emphysema (see Diseases of the 

lungs and pleurae) 
Endocarditis, acute (see Diseases 
of the vascular system) 
malignant (see Diseases of the 
vascular system) 
Enteric fever (see Infectious dis- 
eases — Typhoid) 
Enteritis, acute (see Diseases of 
the intestines) 
chronic (see Diseases of the in- 
testines ) 
Exophthalmic goiter (see Diseases 
of the ductless glands) 

F 
Fever, enteric (see Infectious dis- 
eases — Typhoid ) 
rheumatic (see Infectious dis- 
eases) 
scarlet ( see Infectious diseases ) 

G 

Gallbladder, diseases of the (see 
Diseases of the gallbladder) 

Gallstones (see Diseases of the 
gallbladder) 

Gangrene, pulmonary ( see Diseases 
of the lungs and pleurae) 

Gastric cancer (see Diseases of the 
stomach ) 
ulcer (see Diseases of the stom- 
ach) 



294 



INDEX. 



Gastritis (see Diseases of the 

stomach ) 
General considerations, 272 
Physician and patient, 272 
examination of abdomen, 278 
examination of excretions, 277 
examination of secretions, 277 
knowledge of anatomy, 272 
manipulation, 273 
observations of patient, 272 
obtaining history, 273 
palpation, 276, 277 
patient's confidence, 272 
physical characteristics, 274 
physical examinations, 272, 

273 
physician's bearing, 272 
posture of patient, 273, 274 
test for arteriosclerosis, 276 
Glands, ductless, diseases of the 
( see Diseases of the ductless 
glands ) 
Goiter, exophthalmic (see Diseases 

of the ductless glands) 
Gout (see Constitutional diseases) 



Heart, valvular disease of the (see 
Diseases of the vascular sys- 
tem) 

Hematemesis (see Diseases of the 
stomach ) 

Hemorrhage (see Diseases of the 
pancreas and peritoneum) 

Hodgkin's disease (see Diseases of 
the blood — Pseudoleukemia ) 

Hydronephrosis (see Diseases of 
the kidneys and bladder) 

Hyperchlorhydria (see Diseases of 
the stomach) 



Icterus (see Diseases of the liver) 
Infectious diseases, 216 
Amebic dysentery, 231 

acute, 231 

amebi coli in stools, 231 

chronic, 231 

fever, 231 

indigestion, 231 

liver abscess, 231 

onset sudden, 231 



Infectious diseases — cont'd 
palpation, 231 
perforation, 231 
peritonitis, 231 
symptoms, 232 
Treatment, 232 

diet, 232 

enemata, 232 

intestinal antiseptics, 232 

local treatment, 232 

rest, 232 
Bacillary dysentery, 227 
bacilli dysenterise, 228 
bloody flux, 228 
causes, 227 
epidemic, 227 

Flexner-Harris bacilli, 228 
liver abscess, 228 
onset sudden, 227 
paralysis, 228 
paraplegia, 228 
Shiga bacilli, 228 
symptoms, 227 
tenesmus, 228 
Treatment, 229 

diet, 229 

local applications, 230 

medicinal, 229 

prescriptions, 229, 230 

rectal irrigation, 230 

rest, 229 

serum therapy, 230 
Diphtheria, 251 

bacterial examination of 

throat, 252 
carbonic acid poisoning, 251 
children most susceptible, 251 
diphtheria carriers, 251 
diphtheritic croup, 251 
direct contagion, 251 
discharge from nose, 252 
enlargement of lymph glands, 

252, 253 
indirect contagion, 251 
Klebs-Loeffler bacilli, 252 
membrane, 252, 253 
milk a cause, 251 
otitis media, 251 
sore throat, 252 
streptococci, 251 
symptoms, 251 
temperature, 252 



INDEX. 



295 



Infectious diseases — cont'd 
tonsils, 252 
toxemia, 252 
Treatment, 253 
antitoxin, 254 
bowels, 254 
diet, 254 
hygienic, 253 
intubation, 254 
laryngeal croup, 254 
local treatment, 253 
rest, 254 

specific treatment, 254 
stimulants, 254 
toxin, 254 
tracheotomy, 254 
ventilation, 253 
Malaria, 243 

bilious fever, 245 
chronic malaria, 247 
differentiating typhoid and re- 
mittent fever, 246 
examination of blood, 245, 246 
fever and ague, 244 
herpes labialis, 245 
intermittent fever, 244 
mosquito as cause, 243 
number of types, 243 
pernicious malaria, 246 
protection from mosquito, 243 
pyemia, 245 
remittent fever, 245 
symptoms of chronic malaria, 

247 
symptoms of intermittent fe- 
ver, 244 
symptoms of pernicious ma- 
laria, 246 
symptoms of remittent fever, 

245 
tuberculosis of lungs, 245 
Treatment, 248 
Blaud's pills, 250 
Fowler's solution, 250 
masking solution of qui- 

nin, 249 
mixed treatment, 248 
prescriptions, 248-250 
protection from mosquito, 
248 
Measles, 233 
cough, 233 



Infectious diseases — cont'd 
desquamation, 234 
differentiation of measles and 

small-pox, 234 
eruption, 233 
fever, 233 
hemorrhage, 234 
Koplik's spots, 234 
lobular pneumonia, 234 
mastoid abscess, 234 
onset with coryza, 233 
otitis media, 234 
period of incubation, 233 
Treatment, 235 

cathartics, 235 

convalescence, 235 

cough, 235 

diet, 235 

eruption, 235 

fever, 235 

prescriptions, 235, 236 

rest, 235 
Rheumatic fever (inflammatory 
rheumatism), 255 
acute infectious disease, 255 
acute osteomyelitis, 256 
anemia, 255 
arthritis, 256 
arthritis deformans, 256 
causes, 255 

cerebral rheumatism, 257 
differentiating inflammatory 
rheumatism and tonsillitis, 
255 
examination of urine, 256 
fatality, 257 
fever, 256 

gonorrheal arthritis, 256 
joint changes, 256 
joints, 255 
Kernig's sign, 256 
micro-organisms as cause, 255 
onset sudden, 255 
pulse, 255 

rheumatism simulating men- 
ingitis, 256 
sweat, 255 

Treatment, 257 

clothing, 257 

convalescence, 25P 

diet, 257 

hyperpyrexia, 257 



296 



INDEX, 



Infectious diseases — cont'd 

prescriptions, 258, 259 
rest, 257 
Scarlet fever ( scarlatina ) 3 236 

angina, 236 

differentiating scarlatina and 
measles, 237 

enlargement of lymph glands, 
237 

examination of urine, 238 

eruption, 237 

inflammatory rheumatism, 238 

milk as cause, 236 

onset sudden, 237 

otitis media, 238 

polyarthritis, 238 

symptoms, 237 

temperature, 237 

tongue indications, 237 
Treatment, 239 

cardiac failure, 241 
care of mouth, 239 
clothing, 239 
convalescence, 243 
delayed eruption, 242 
delirium, 241 
examination of urine, 242 
fever, 240 
hydrotherapy, 240 
Loeffler's solution, 240 
nephritis, 242 
prescriptions, 239-243 
prophylaxis, 239 
stimulants, 241 
twitching, 241 
ventilation, 239 
Typhoid (enteric fever), 216 

common in adults, 216 

enlargement of spleen, 218 

fatality, 220 

fever, 217 

intestinal hemorrhage, 217 

mistaken for appendicitis, 217 

onset sudden in children, 216 

onset usually gradual, 216 

pea-soup stools, 218 

pulse, 218 

rose spots, 217 

signs of perforation, 219 

signs of peritonitis, 219 

simulating malaria, 218 

surgery, 219 



Infectious diseases — cont'd 
sweating, 218 
symptoms, 216 
Widal test, 218 
Treatment, 220 
baths, 222 
bed sores, 225 
bowels, 223 
care of mouth, 225 
cold packs, 222 
convalescence, 227 
diarrhea, 225 
diet, 220 

diet of McCrea, 220 
diet of Osier, 220 
diet of Shattuck, 220 
hemorrhage, 226 
hydrotherapy, 221 
intestinal antiseptics, 223 
liquids, 221 
medicinal antipyretics, 

223 
meteorism, 226 
perforation, 227 
prescriptions, 224-226 
surgery, 227 
tonics, 227 
Inflammatory rheumatism (see In- 
fectious diseases — Rheu- 
matic fever) 
Interstitial nephritis, chronic (see 
Diseases of the kidneys and 
bladder) 
pneumonia, chronic (see Diseases 
of the lungs and pleurae) 
Intestines, diseases of the ( see Dis- 
eases of the intestines) 



Jaundice ( see Diseases of the liver 
— Icterus ) 



Kidney, movable (see Diseases of 
the kidneys and bladder) 

Kidneys, diseases of the (see Dis- 
eases of the kidneys and 
bladder ) 



Laennec's cirrhosis (see Diseases of 
the liver — Portal cirrhosis) 



INDEX. 



297 



Liver, abscess of the (see Diseases 

of the liver) 
cancer of the (see Diseases of 

the liver) 
diseases of the (see Diseases of 

the liver) 
Leukemia (see Diseases of the 

blood) 
Lobar pneumonia (see Diseases of 

the lungs and pleurae ) 
Lobular pneumonia (see Diseases 

of the lungs and pleurae — 

Broncho-pneumonia ) 
Lungs, diseases of the (see Dis- 
eases of the lungs and 

pleurae ) 
edema of the (see Diseases of 

the lungs and pleurae) 

M 

Malaria (see Infectious diseases) 
Malignant endocarditis (see Dis- 
eases of the vascular sys- 
tem) 
Measles (see Infectious diseases) 
Movable kidney (see Diseases of 

the kidneys and bladder) 
Mucous colitis ( see Diseases of the 

intestines) 
Myxedema (see Diseases of the 
ductless glands) 

N 

Nephritis, acute (see Diseases of 
the kidneys and bladder) 
chronic interstitial ( see Diseases 
of the kidneys and bladder) 
chronic parenchymatous (see 
Diseases of the kidneys and 
bladder ) 
Nephrolithiasis ( see Diseases of the 
kidneys and bladder) 



Obstruction of the bowel (see Dis- 
eases of the intestines) 



Palpitation (see Diseases of the 
vascular system) 



Pancreas, carcinoma of the (see 
Diseases of the pancreas and 
peritoneum ) 
diseases of the (see Diseases of 
the pancreas and perito- 
neum) 

Pancreatic cysts (see Diseases of 
the pancreas and perito- 
neum) 

Pancreatitis, acute (see Diseases 
of the pancreas and perito- 
neum) 
chronic ( see Diseases of the pan- 
creas and peritoneum) 

Parenchymatous nephritis, chronic 
(see Diseases of the kidneys 
and bladder) 

Patient, physician and (see Gen- 
eral considerations) 

Pectoris, angina (see Diseases of 
the vascular system) 

Pericarditis (see Diseases of the 
vascular system) 

Peritoneum, diseases of the (see 
Diseases of the pancreas and 
peritoneum) 

Peritonitis, acute (see Diseases of 
the pancreas and perito- 
neum) 

Pernicious anemia ( see Diseases of 
the blood) 

Physician and patient (see Gen- 
eral considerations) 

Portal cirrhosis (see Diseases of 
the liver) 

Pleurae, diseases of the (see Dis- 
eases of the lungs and 
pleurae) 

Pleurisy, acute (see Diseases of 
the lungs and pleurae) 

Pneumonia, chronic interstitial 
(see Diseases of the lungs 
and pleurae) 
lobar (see Diseases of the lungs 

and pleurae) 
lobular (see Diseases of the 
lungs and pleurae — Broncho- 
pneumonia) 

Pseudoleukemia (see Diseases of 
the blood) 



298 



INDEX. 



Pulmonary gangrene (see Diseases 
of the lungs and pleurae) 
tuberculosis (see Diseases of the 
lungs and pleurse) 

Purpura (see Diseases of the 
blood) 

Pyelitis (see Diseases of the kid- 
neys and bladder) 

R 

Rheumatic fever (see Infectious 
diseases ) 

Rheumatism, inflammatory ( see 
Infectious diseases — Rheu- 
matic fever) 



Scarlatina (see Infectious diseases 
— Scarlet fever) 

Scarlet fever (see Infectious dis- 
eases) 

Stomach, diseases of the (see Dis- 
eases of the stomach) 

Suppurative cholangeitis (see Dis- 
eases of the gallbladder) 

System, vascular, diseases of the 
( see Diseases of the vascular 
system) 



Tuberculosis, pulmonary (see Dis- 
eases of the lungs and 
pleurse ) 

Typhoid (see Infectious diseases) 

U 

Ulcer, gastric (see Diseases of the 
stomach ) 

Uremia (see Diseases of the kid- 
neys and bladder) 



Valvular diseases of the heart (see 
Diseases of the vascular sys- 
tem) 

Vascular system, diseases of the 
(see Diseases of the vascu- 
lar system) 

Visceroptosis (see Diseases of the 
intestines ) 



Yellow atrophy, acute (see Dis- 
eases of the liver) 






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